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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003744
Report Date: 11/04/2021
Date Signed: 11/04/2021 02:55:00 PM

Document Has Been Signed on 11/04/2021 02:55 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: 75DATE:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marjan ArastooTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lydia Martinez, Albert Marin, Norman Woodridge, and Jerome Haley made an unannounced Case Management visit to the facility on 11/02/2021. LPAs met with Administrator (AD) Marjan Arastoo and reason for the visit was explained.

LPAs Martinez, Marin, Woodridge and Haley conducted a tour of the interior and exterior of the facility, which included but not limited random client rooms, common bathrooms, kitchen, dining area, and TV room.

LPA’s observed and AD Marjan confirmed she was the only Caregiver/MedTech for the 75 clients present during the visit. AD Marjan also confirmed she only has the following personnel and provided LPA Martinez with current copy of LIC500-Personnel Report: 1 MedTech/Caregiver who works Friday 8am-4pm, Saturday and Sunday 3pm-11pm, 1 Caregiver who works Friday 3pm-11pm and Saturday 7am-3pm, 1 Housekeeper works Monday thru Friday 7am-12pm, 1 Housekeeper who works Monday thru Thursday 8am-4pm. There are no Housekeepers on weekends. No Activity Director and the Cook resigned. LPA’s observed Assistant Administrator Abdol Arastoo making lunch which consisted of Vegetable/Pasta soup, mixed salad, cottage cheese, saltine crackers, half apple and Tea. There was plenty of frozen food observed such as chicken, beef, and hot dogs/corn dogs. There was milk, bread, vegetables, and fruit.

LPA’s observed and Staff Abdol confirmed ice maker is still broken. LPAs observed the following during the walk through: Dining tablecloths have not been replaced or cleaned, doors are still tied open with plastic bags on second floor, both common bathrooms on second floor had no toilet paper, paper towels and soap dispensers were empty. Upon checking random client rooms, Room 217 was noted to be filled with cigarette smoke and client in the room. Smoke Alarm was non-operational in the room. LPA's also noted Smoke Alarm in room 107 was hanging and non-operational. AD Marjan acknowledged call system is not working either.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PLUS
FACILITY NUMBER: 306003744
VISIT DATE: 11/04/2021
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No report or citations were issued at the time of the visit due to time constraints. Based on the observations made during 11/02/2021 inspection, deficiencies are being cited on today’s date per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties will be assessed for repeat violation within the last 12 months.

An exit interview was conducted with AD Marjan, copy of this report and Appeal Rights will be emailed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2021 02:55 PM - It Cannot Be Edited


Created By: Lydia Martinez On 11/03/2021 at 01:00 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: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
80020

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Fire Clearance: (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidence of:
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AD agrees to repair/replace Smoke Alarms in rooms 107 and 217, and test all Smoke Alarms. Will repair and/or replace where needed. AD to submit Self Certification that POC has been completed by end of business day of 11/08/2021
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LPA's observed Smoke Alarms were non- operational in Client rooms 107 and 217. This is an immediate threat to all the Clients in care.
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Type A
11/08/2021
Section Cited
CCR80078(a)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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AD agrees to submit a written plan of action to ensure staff coverage is available at all times. POC to be submitted to LPA by 11/08/2021
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Facility lacks adequate staffing. AD is only MedTech/Caregiver Monday thru Thursday for the 75 clients. There is no Cook, no Activity Director and No Housekeepers on the weekends. This is an immediate threat to all the Clients in care.
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This is a second violation in 12 months. An immediate Civil Penalty is assessed today.
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:Marina Stanic
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/04/2021 02:55 PM - It Cannot Be Edited


Created By: Lydia Martinez On 11/04/2021 at 09:32 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY CARE PLUS
FACILITY NUMBER: 306003744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
80087(a)

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Buildings and Ground: (a) The facility shall be … in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Based on observation, the licensee allowed the following conditions at the facility:
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AD agrees to submit a plan of action by close of business day of 11/08/2021 to CCLD.
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Ice machine is non-operable, beds in disrepair, dining room table cloths are dirty, which poses an immediate health and safety risk to clients in care.
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This is a second violation in 12 months. An immediate Civil Penalty is assessed today.
Type A
11/08/2021
Section Cited
CCR85088(f)(1)(A-C)

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Fixtures, Furniture, Equipment and Supplies. Facilities shall meet the following signal system requirements: all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system...This requirement is not met as evidenced by:
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AC agrees to submit a plan of action by close of business day of 11/08/2021 to CCLD
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Based on observation and interview the AD did not maintain an operational signal system in the facility. This posses an immediate risk to the health and safety of clients in care.
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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:Marina Stanic
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
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