198601740-5-27-2025-28-AS-THEA-DH3TZ5-20250527150946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601740
Report Date: 05/27/2025
Date Signed: 05/27/2025 03:11:18 PM

Document Has Been Signed on 05/27/2025 03:11 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 OF LIFE ACADEMY		FACILITY NUMBER:	198601740
ADMINISTRATOR/ DIRECTOR:	NNAEMEKA EZENAGU		FACILITY TYPE:	775
ADDRESS:	8439 CALIFORNIA AVENUE		TELEPHONE:	(562) 372-4750
CITY:	SOUTH GATE	STATE: CA	ZIP CODE:	90280
CAPACITY: 66		CENSUS: 57	DATE:	05/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:38 PM
MET WITH:	Ezinne Sonia Okereke-Assistant Program Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. LPA met with Ezinne Sonia Okereke - Assistant Program Administrator, and the purpose for the visit was explained. The facility is licensed to serve 66 Ambulatory Only Adults ages 18 and over. This is a single- story facility located in South Gate, Ca. A tour of the facility includes: Front building with large activity room and restroom, Back building with 2 restrooms. Office, outdoor shaded activity area, 2 staff office, 1 staff office has kitchen, medication and staff restroom. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility maintains the required Infection Control Plan. Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and are fully charged. No bodies of water were observed at the facility. The hot water temperature was tested and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, poisons and hazardous items are stored in a secured/locked storage closet and inaccessible to clients. Clients have a water station available in the kitchen and clients are provided water bottles. Client restroom in the front building did not have an operating light during tour, one of the client restrooms in the far back building was under construction during visit and no incident report was submitted indicating that facility will be undergoing such repair (citation will be issued and details can be found on the LIC809-D page). (Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 OF LIFE ACADEMY	FACILITY NUMBER: 198601740
	VISIT DATE: 05/27/2025

NARRATIVE

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Operational Requirements: The facility has the appropriate fire clearance. Staff are knowledgeable on their reporting requirements.
Staffing: There appears to be sufficient staffing at all times in the facility. There are at least 2 staff members on duty any time there are clients in the facility.
Personnel Records-Training: Staff files were readily available during visit. LPA reviewed 6 staff files, each file reviewed have criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Program Director Joshua Corzantes has the required the education, proper training and experience to meet the requirements. During file review 4 out of 6 staff were missing their Health Screening and negative TB results, citation will be issued and details can be found on the LIC809-D page.
Client Records-Incident Reports: Client files are kept in a secure location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Consent Forms, and Appraisal Needs & Services Plan. LPA reviewed 5 client records only 1 out of the 5 client files were missing the required Physician Report with negative TB result, citation issued and details can be found on LIC809-D page.
Client Rights-Information: Client Rights Poster is posted within the facility.
Food Service: Pesticides and other similar toxic substances are not stored with the food.
Health Related Services & Incidental Medical & Dental: Clients with incontinence at the facility are kept clean and dry, and the facility is free of any odors. There was only one client during todays visit that has medication stored at facility, medication is properly labeled in their original containers and stored in a locked cabinet within main office/kitchen cabinet.
Disaster Preparedness: There is an Emergency Disaster Plan with contact numbers and relocation sites. The fire drill log was not available during visit, therefore, proof of the required fire drills was not provided to LPA, citation will be issued and details can be found on the LIC809-D page.
Emergency Intervention: LPA reviewed 6 staff files and each staff had valid CPI certificates.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on the LIC809-D pages.

Exit interview was held and a copy of the report and appeal rights will be emailed to info@qualityoflifebmp.net

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2025 03:11 PM - It Cannot Be Edited

Created By: Tena Herrera On 05/27/2025 at 02:44 PM

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 OF LIFE ACADEMY	FACILITY NUMBER: 198601740
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82087(a)

Buildings and Grounds

(a) The program site 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during tour LPA observed front building restroom light to be non-operable and back building restroom to be having work done and non-operable, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Administraor/Licensee to submit proof of light being operable in front restroom and back restroom to be operable, with photos/videos by POC due date. Photos/Videos can be emailed to LPA at tena.herrera@dss.ca.gov

Type B

Section Cited

CCR

82066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (10) A health screening, as specified in Section 82065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as LPA reviewed 6 staff files and 4 out of the 6 files were missing their Health Screening and negative TB results, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Administraor/Licensee to submit proof of health screening and negative TB results for staff 1-4 (a seperate confidential name list of employees will be provided to Administrator), proof may be submitted via email to LPA by POC due date. tena.herrera@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 05/27/2025 03:11 PM - It Cannot Be Edited

Created By: Tena Herrera On 05/27/2025 at 02:44 PM

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 OF LIFE ACADEMY	FACILITY NUMBER: 198601740
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82069(a)

Client Medical Assessments

(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 1 out of 5 client files reviewed during visit was missing the required Physician Report, client was admitted to facility in January 2025, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Administraor/Licensee to submit a copy of the required physican report and negative TB result via email by POC due date. tena.herrera@dss.ca.gov

Type B

Section Cited

CCR

82023(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as proof of the required drills could not be provided to LPA during visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Administraor/Licensee to submit a copy of the required disaster/emergency drill to LPA by POC due date, additionally the regulation must be reviewed and a copy of the completed and signed LIC9098 Proof of Correction must be emailed to LPA by POC due date, this will indicate that moving forwared regulation will be followed per the requirement. tena.herrera@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC809 (FAS) - (06/04)

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