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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003744
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:45:52 PM

Document Has Been Signed on 09/13/2023 03:45 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:QUALITY CARE PLUSFACILITY NUMBER:
306003744
ADMINISTRATOR:MARJAN ARASTOOFACILITY TYPE:
735
ADDRESS:1652 W. BROADWAYTELEPHONE:
(714) 635-6561
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 80CENSUS: 69DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Marjan ArastooTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Marjan Arastoo and discussed the purpose of the inspection.

During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and observed the following:

The facility is a two-story building with 40 client rooms, a dining room, kitchen, medication room, office and a recreation room with a TV. LPA observed all fire extinguishers are fully charged. All resident bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The front courtyard has a shaded sitting area. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 107.0 and 112.0 F degrees. Food menu was posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Disaster drill log indicated last drill was conducted on 2/07/23; a Deficiency was cited on today's date. Stove burners, microwave, washer, and dryer were all inspected. Sharps and all toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cart was observed to be locked inside the medication room. LPA reviewed seven client files and observed Medication Administration Records (MARs) were inaccurate in four client files; a Deficiency was cited on this date. LPA reviewed three staff files and interviewed seven clients and two staff.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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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Document Has Been Signed on 09/13/2023 03:45 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/13/2023 at 02:28 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY CARE PLUS
FACILITY NUMBER: 306003744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, AD admission, and record review, the licensee did not comply with the section cited above as four out of seven client MARs show medications were administered on dates they were not administered, which poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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AD stated an in-service training will be held with staff responsible for administering medication. AD will provide LPA with proof of in-service via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2023 03:45 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/13/2023 at 02:28 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY CARE PLUS
FACILITY NUMBER: 306003744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as a disaster drill has not been conducted in seven months, which poses a potential safety risk to persons in care.
POC Due Date: 10/13/2023
Plan of Correction
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AD stated they would update facility protocol to do quarterly drills and will provide LPA with most recent disaster drill log via email by POC date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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