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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004700
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:49:07 PM


Document Has Been Signed on 03/11/2022 04:49 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 SENIOR LIVING HOUSE #2FACILITY NUMBER:
306004700
ADMINISTRATOR:MARIA DOLORES D. TENTEFACILITY TYPE:
740
ADDRESS:26791 MORENA DRIVETELEPHONE:
(949) 309-9314
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Maria Tente, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Administrator Maria Tente after explaining the purpose of the visit. Two caregivers are also present at the time of the visit.

At approximately 3:25pm, LPA accompanied by Administrator toured the inside and outside of the facility. There are currently five (5) residents in care, none of which are on hospice. Residents are observed to be relaxing in their bedrooms or in the common areas and appear well taken care of. The five (5) bedrooms are observed to be including all necessary components. Facility appears to be clean, sanitary and free of odors in all areas inspected.
LPA observed the facility has COVID-19 Precautions posters and required department postings. Bathrooms are however observed to be missing mandatory hand washing signs. Facility has an adequate supply of PPE. A LIC808 Mitigation has been submitted and approved by LPA Albert Marin on 07/15/2021.
LPA observed a sufficient supply of food and water. LPA observed that the facility does not have an emergency supply of food and water. A 30-day supply of medication is stored and locked. . LPA toured the outside of the facility. Outdoor furniture is present for the clients' enjoyment and outside space is free of clutter and debris. There are no bodies of water on the premises.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and a Technical Advisory is also being issued. This report was reviewed with facility representative and a copy of this report and appeals rights was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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 03/11/2022 04:49 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: QUALITY SENIOR LIVING HOUSE #2
FACILITY NUMBER: 306004700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(2)
"A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order."

This requirement is not met as evidenced by: At the time of the visit, two residents' beds are observed to have half rails in place. When LPA requested
Deficient Practice Statement
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Based on today's observations, the licensee did not comply with the section cited above regarding two residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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Licensee will provide copy's of the physician's orders for bed rails to LPA.
Type B
Section Cited
CCR
87468.1(a)(2)
a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by: Toxic substances such as room deodorizer and disinfectant are present in cabinets under each of the resident's bathroom sinks
Deficient Practice Statement
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Based on today's observation, the licensee did not comply with the section cited above in two separare instances which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
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All toxic substances will be stored in the locked cabinet under the kitchen sink at all times.

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 OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3