306004399-3-6-2025-22-AS-BLOZ-DEHVVN-20250306154638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004399
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:47:06 PM

Document Has Been Signed on 03/06/2025 03:47 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	QUALITY SENIOR LIVING		FACILITY NUMBER:	306004399
ADMINISTRATOR/ DIRECTOR:	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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Caregiver Felijun Casuyon		TIME VISIT/ INSPECTION COMPLETED:	04:02 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 Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Maria Tente was notified via telephone but could not arrive to assist with the inspection. LPA observed that Administrator Maria Tente has a valid Administrator certificate which expires on December 3, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for two. The facility is a two story home with five resident bedrooms, one of which is shared, three staff bedrooms, four resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by a care giving staff conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, two of which are on hospice, and two care giving staff present. LPA observed residents relaxing in the living room as well as their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the four resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 108.1 and 113.3 degrees Fahrenheit. LPA observed that one of the shared resident bathrooms had a common wash cloth for all resident use. LPA observed the second story of the home to be for staff use only and to be off limits to residents in care. LPA observed all three staff bedrooms to be locked and inaccessible to residents in care. LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. CONTINUED ON LIC809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY SENIOR LIVING	FACILITY NUMBER: 306004399
	VISIT DATE: 03/06/2025

NARRATIVE

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LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed that the lock on the kitchen cabinet where knives and sharps are being stored was inoperable at the time of visit making them accessible to residents in care. A fire extinguisher is located in the kitchen and it was observed to be charged and serviced on May 30, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility has not conducted an emergency disaster drill. The centrally stored medication is kept in a locked cabinet in the kitchen. A First Aid kit is stored in the locked kitchen cabinet and it was observed to have all the required components. The door leading to the attached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed chemicals and toxins to be stored in the locked garage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side of the facility is self-latching and can be opened in an evacuation. LPA observed a pool located in the backyard. The pool is adequately fenced and is kept locked for resident safety.

LPA reviewed all five resident files. LPA observed that the facility did not have a Pre-admission appraisal on file for Resident #1 (R1), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). LPA observed the facility did not have a Reappraisal on file for R1, R2, R3, R4, and R5. LPA observed that the facility did not have a Medical Assessment on file for R4 and R5. LPA reviewed all five residents’ medication and medication records. LPA reviewed three staff files. LPA observed that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) did not complete the required annual training for the year of 2024. LPA observed that 0 out of the 3 care giving staff do not have a valid CPR training card on file. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies are being cited per Title 22 of the California Code of Regulations. LPA spoke with Administrator Maria Tente via telephone who provided permission for Caregiver Felijun Casuyon to be the authorized representative since she could not arrive to assist with the inspection. An exit interview was conducted with the facility's authorized representative. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2025 03:47 PM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY SENIOR LIVING	FACILITY NUMBER: 306004399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on 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. During a tour of the kitchen, LPA observed that the lock on the kitchen cabinet where knives and sharps are being stored was inoperable making them accessible to residents in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	A caregiver removed the knives and sharps from the cabinet during the visit and placed them in the garage. POC cleared at time of visit.

Type A

Section Cited

HSC

1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During file review, LPA observed that the facility has not completed any emergency disaster drills.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	AD agreed to complete an emergency disaster drill. AD will submit proof of the emergency disaster drill to LPA via email or fax by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2025 03:47 PM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY SENIOR LIVING	FACILITY NUMBER: 306004399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based oncrecord review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that 0 out of the 3 care giving staff do not have a valid CPR training card on file.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to have all staff complete CPR training. AD wil submit proof of a valid CPR training card to LPA via email or fax by POC date.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) did not complete the required annual training for the year of 2024.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to have all staff complete the required annual training. AD will submit proof of training completion to LPA via email or fax by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2025 03:47 PM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY SENIOR LIVING	FACILITY NUMBER: 306004399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed that the facility did not have a Pre-admission appraisal on file for Resident #1 (R1), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5).
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to complete a Preappraisal for R1, R3, R4, and R5. AD will submit the completed Preappraisals for all four residents to LPA via email or fax by POC date.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed that the facility did not have a Medical Assessment on file for Resident #4 (R4) and Resident #5 (R5).
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to get a Medical Assessment for R4 and R5. AD will submit the Medical Assessment's for R4 and R5 to LPA via email or fax by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 03/06/2025 03:47 PM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUALITY SENIOR LIVING	FACILITY NUMBER: 306004399
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the facility did not have a Reappraisal on file for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5).
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	AD agreed to complete Reappraisals for R1, R2, R3, R4, and R5. AD will submit the completed Reappraisals for all five residents to LPA via email or fax by POC date.

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.

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 03/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025

LIC809 (FAS) - (06/04)

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