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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003744
Report Date: 12/13/2021
Date Signed: 12/13/2021 04:05:39 PM

Document Has Been Signed on 12/13/2021 04:05 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: 73DATE:
12/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marjan ArastooTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez, made an unannounced visit to the facility to conduct a Case Management inspection to check on Health and Safety and Plan of Corrections for the violations cited during previous visits. LPA met with Licensee/Administrator (AD) Marjan Arastoo and stated the reason for the visit.

LPA Martinez conducted a tour of the facility’s physical plant, and no immediate health/safety hazards were observed. LPA inspected client rooms 101 thru 114 and client rooms 201 thru 223, kitchen, common bathrooms, and food service. Facility's food supply was observed to be in quantity to meet the regulatory requirements during this inspection. Facility menu is posted and meal service for dinner was consistent with the posted menu. Lunch meal for today was observed as cheeseburger, fries, chips, corn, choice of watermelon and/or persimmon. Fruit juice, tea and water were available for consumption. Hygiene supplies were observed centrally stored in the office and hallway locked cabinets. Common bathrooms were clean and observed to have toilet paper, paper towels and hand soap. Staffing was observed as follows: 1 Administrator, 2 Carestaff, and 2 Housekeepers. Staff Abdul Arastoo is preparing and serving facility meals while Cook returns on 12/14/2021. LPA was informed by AD she has 2 prospective staff, just waiting on fingerprint clearance. AD to keep LPA Martinez informed on status of new staffing/hires.



Facility currently has 73 clients. AD was reminded again that she can not admit new clients until the facility is fully staffed to which AD acknowledged. AD Marjan agreed to start a Maintenance Log for staff to log repairs and/or concerns needed in the facility.

LPA Martinez along with AD Marjan conducted walk through of all client rooms and observed following; Rooms 101, 202, 202A, 204, 205, 206, 207, 209, 219, and 223 need mattress replaced; Rooms 201A and 223 needs blinds replaced, Room 214 bathroom sink has water leak and room 220 bathroom does not flush. AD agreed to do conduct sweep of all clients rooms and replace pillows where needed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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: 12/13/2021
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LPA has observed handyman in past visits and today, replacing floors, painting walls, replacing broken blinds and replacing/repairing beds in several client rooms. LPA observed Room 207 with no bathroom door as it was leaning on wall inside room, holes on wall, broken blinds and dirty floor. AD stated she will start eviction on Client 1 for destroying room and breaking house rules. LPA noted strong smell of smoke in Room 223. Per AD she has given Client 2 several warnings of not smoking/breaking house rules and will initiate 30-day eviction. LPA noted broken chairs have been replaced where needed, broken closet doors repaired and holes patched up in client rooms where needed. Painting is to follow.

LPA observed locked hallway cabinets to contain new/fresh linens, towels and new blankets.

Based on the observation made during today’s inspection, deficiency will be cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D and LIC811 Confidential Names. Civil penalty will be assessed for repeat violation within the last 12 months.

An exit interview was conducted with AD Marjan, a copy of report and Appeal Rights will be emailed.




SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2021 04:05 PM - It Cannot Be Edited


Created By: Lydia Martinez On 12/13/2021 at 12:31 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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited
CCR
80087(a)

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Buildings and Grounds (a) The facility shall be clean, safe, sanitary … at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: This requirement was not met as evidenced by:
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Licensee/AD agrees to replace mattresses and make repairs as noted. Will conduct sweep of all client rooms and replace pillows where needed. All by POC due date of 12/16/2021. LPA to conduct POC visit.
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Based on observation, client rooms 101, 202, 202A, 204, 205, 206, 207, 209, 219, and 223 have worn out mattress; old/soiled pillows were observed; 201A and 223 have broken blinds, and 214 has leaking sink, which poses a potential health risk to client's in care.
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This is a second violation in 12 months. An immediate Civil Penalty is assessed today.

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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: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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