306004399-4-4-2022-22-AS-KSGH-CCQUN9-20220321154335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004399
Report Date: 03/21/2022
Date Signed: 04/04/2022 09:22:47 AM

Document Has Been Signed on 04/04/2022 09:22 AM - 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 SENIOR LIVING		FACILITY NUMBER:	306004399
ADMINISTRATOR:	MARIA DOLORES D TENTE		FACILITY TYPE:	740
ADDRESS:	24262 GRASS STREET		TELEPHONE:	(949) 215-3087
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 4	DATE:	03/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Felijun Casayou, caregiver		TIME COMPLETED:	04:00 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 Analysts (LPAs) Kevin Saborit-Guasch and Claudia Gutierrez made an unannounced visit to the facility in order to conduct a required annual inspection. LPAs arrived at facility, were greeted and granted entry by Felijun Casayou, caregiver after explaining the purpose of the visit. Administrator Maria Tente was called on the phone but was unable to assist with the visit in person. At approximately 2:35pm, LPAs accompanied by caregiver toured the inside and outside of the facility. There are currently four (4) residents in care, one of (1) of which is currently on hospice. Residents are observed to be relaxing in their bedroom or in the common areas are appear well taken care of. The bedrooms include all necessary components and sufficient quantity of linen is observed also. Both bathrooms are equipped with grab bars and slip mats. The kitchen drawer in which sharp instruments are stored is observed to have a non-functional magnetic lock. The door leading to the garage is also left open during the daytime in spite of the presence of cleaning supplies and detergent there. Caregiver indicates that it is being locked at night only. LPAs observed the facility has COVID-19 Precautions posters and required department postings. Administrator licenses for Nelson Acsay, Maria Tente and Ina Czarina Chua are posted by are all outdated. Facility has an adequate supply of PPE and emergency supplies. A LIC808 Mitigation has been submitted on 02/23/2021. LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored under lock. Daily/weekly pillboxes are observed in front of the cupboard with pills left in them. LPAS advised caregiver to store pillboxes inside the locked compartment as well. LPAs toured the outside of the facility. Outdoor furniture is present for the residents' enjoyment in the backyard. The gates on the side of the house are self-latching and can easily be opened in an evacuation. A swimming pool in the backyard is observed to be adequately fenced and equipped with a self-latching gate.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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 3

Document Has Been Signed on 04/04/2022 09:22 AM - It Cannot Be Edited

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 SENIOR LIVING	FACILITY NUMBER: 306004399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: the magnetic lock securing the drawer contaning knives and sharp instruments is broken and not functional, as observed by LPAs during the visit.
	Deficient Practice Statement
1 2 3 4	Based on this observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2022
	Plan of Correction
1 2 3 4	A replacement lock or new locked storage for sharp instruments and other dangerous items has to be procured and installed instead of the defective magnetic lock currently in place.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 SENIOR LIVING	FACILITY NUMBER: 306004399
	VISIT DATE: 03/21/2022

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
26
27
28
29
30
31
32

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is also issued in regards to the outdated licenses, lock on the swimming pool gate, unlocked pillboxes and unlocked garage door. This report was reviewed with facility representative and a copy of this report and appeals right was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3