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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600773
Report Date: 01/17/2023
Date Signed: 01/17/2023 12:25:39 PM

Document Has Been Signed on 01/17/2023 12:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:QUALITY CARE HOMEFACILITY NUMBER:
198600773
ADMINISTRATOR:FLORESITA P LIMFACILITY TYPE:
735
ADDRESS:990 MURCHISON AVENUETELEPHONE:
(909) 620-7655
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 6CENSUS: 5DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Floresita P Lim AdministratorTIME COMPLETED:
12:29 PM
NARRATIVE
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Licensing Program Analyst Lopez conducted an unannounced annual inspection visit. LPA was allowed entry to this home by the Facility Administrator Floresita LIm. LPA discussed the purpose of today's visit. This home is for Developmentally Disabled individuals ages 18 to 59. The (5) Clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center. Annual licensing fees are current.

This is a single story home with 4 bedroom (one of which is designated for staff), 3 bathrooms, living room, den, office, kitchen and dining area.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Three client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Three client rooms were equipped with alcohol-based hand sanitizer.
· Five (5) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were not observed wearing masks initially.
· Some clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
Deficiencies cited per Title 22 Health and safety code, See 809D for details.

Exit interview was conducted with Administrator Floresita LIm. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/17/2023 12:25 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/17/2023 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: QUALITY CARE HOME
FACILITY NUMBER: 198600773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The water temperture measured 123.3 degrees F in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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Water temperture was corrected during visit. ****No Further actions is required****
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/17/2023 12:25 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/17/2023 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: QUALITY CARE HOME
FACILITY NUMBER: 198600773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Two staff were not wearing face mask which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2023
Plan of Correction
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Administrator will provide training on infection control procedures to all staff and send proof to LPA by POC date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Room 1 had broken dresser and room 2 is in need of painting to cover up patches which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Administrator repaired dresser drawer in room 1 during visit and will paint room 2 by POC date ad send proof to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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