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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801961
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:16:03 PM

Document Has Been Signed on 01/18/2024 03:16 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAREMAX, INC. - QUIETWOOD HOMEFACILITY NUMBER:
216801961
ADMINISTRATOR:YANG, WEI & LI,JUANFACILITY TYPE:
735
ADDRESS:490 QUIETWOOD DRIVETELEPHONE:
(415) 225-6868
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Member, Jocelyn Farreau, and Administrator Willie YangTIME COMPLETED:
03:20 PM
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At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Jocelyn Farreau. Licensee, Willie Yang, arrived to the facility at approximately 12:35PM and Administrator, Agnes Dizon arrived at approximately 12:40PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 1 ambulatory and 3 non-ambulatory clients with a total capacity for 4 Clients. Upon arrival, LPA was informed that there were 4 clients in care, with 3 clients out of the community.

At approximately 12:45PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:50M, LPA conducted a walk-though of the facility with Licensee. LPA observed the following: The facility was found to be clean with all exits free from obstruction. Facility had emergency lighting. Facility is a two story building with 4 Client bedrooms, 2 staff rooms, 3 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. During walk-through LPA observed that the hot water temperatures were measured at 122.6F, 121.4F, 120.2F, 122.7F (this deficiency has been cited, see LIC809D, regulation 80088(e)(1)). LPA also observed that the temperature in the facility was 62 degrees upon arrival. Per conversation with Licensee and staff members, the staff and clients just returned from an outing. When the house is empty, they turn the thermostat off and turn it back on when they return. LPA observed facility staff immediately turn on thermostat which was shown to be set to 71 degrees (See Technical Advisory, see LIC9102, regulation 80088(a)(1)).

At approximately 1:45PM, LPA reviewed staff and client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure. Administrator's Certificate for Willie Yang (6010060735) expired on 10/16/2023. Review of Department of Social Services Administration Certification website indicated that the certificate renewal has been pending with payment received on 10/07/2023.
Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAREMAX, INC. - QUIETWOOD HOME
FACILITY NUMBER: 216801961
VISIT DATE: 01/18/2024
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Continued from LIC809

Fire extinguishers were last inspected October 2023. Smoke detectors and carbon monoxide detectors were tested and operational. The last facility fire/disaster drill was conducted in January 2024. LPA observed that facility does not have an evacuation chair on-site per Health and Safety Code. Per discussion with Licensee, all clients live on the first floor and are ambulatory. LPA observed Licensee purchase evacuation chair during visit (See Technical Advisory, LIC9102, H&S Code 1565(f)(1)).

LPA also followed up on an incident report submitted to Community Care Licensing (CCL).


Incident Report 1: CCL received an incident report on 10/30/2023. Report states that on 10/28/2023, facility staff observed that the locked medication cabinet was broken with 2 days worth of medication missing. Report states that Client 1 (C1) has a behavior and history of taking other people's possessions and disposing of them by flushing them down a drain. Staff observed C1 vomit after incident. Staff took C1 to be evaluated by medical personnel in the event C1 ingested the medication. Evaluation concluded that C1 did not ingest any medication. Facility continued to monitor and observe C1 for any changes in baseline. Facility made all appropriate notifications per regulation.

LPA requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610D)
  • Updated Personnel Report (LIC500)
  • Surety Bond (LIC402)
  • Register of Clients/Residents (LIC9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to CCL by due date of 2/17/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC809D, LIC9102, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/18/2024 03:16 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 01/18/2024 at 02:38 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CAREMAX, INC. - QUIETWOOD HOME
FACILITY NUMBER: 216801961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observations made, the Licensee did not comply with the section cited above. LPA observed that the sinks in the facility measured at 122.6F, 121.4F, 120.2F, 122.7F. This poses a potential health, safety, and personal rights risk to clients in care.
POC Due Date: 01/28/2024
Plan of Correction
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Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day starting 01/19/2024. Log to include location of sink and time when water was checked. Log to be submitted to CCL for review and approval by POC due date 01/28/2024.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024


LIC809 (FAS) - (06/04)
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