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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004700
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:33:09 PM


Document Has Been Signed on 11/07/2023 01:33 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: 4DATE:
11/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Maria Dolores- AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after observing a deficiency while conducting a complaint investigation in connection to Complaint Control Number: 22-AS-20231101095717. LPA explained the purpose of this Case Management-Deficiencies visit to Administrator Maria Dolores.

While investigating the complaint investigation mentioned above, LPA verified upon arrival approximately 9:15am that Staff #1 (S1) and Staff #2 (S2) were not listed on the Department's Licensing Information System (LIS) Facility Personnel Report Summary printed on November 3, 2023 and the Guardian Employee Roster printed on today's date. LPA verified that S1 and S2 were fingerprint cleared however were not associated to the facility since their date of employment, September 24, 2023. Therefore, the preponderance of evidence standard has been met as the facility did not ensure that S1 and S2 were associated as required by the Title 22 Regulations, 87355 Criminal Record Clearance.

A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D. An immediate civil penalty is being assessed. See the attached LIC421BG.

An exit interview was conducted with Administrator Maria Dolores, and a copy of this report including the LIC809D, LIC421BG, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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Document Has Been Signed on 11/07/2023 01:33 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: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance "(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance..."
This requirement was not met as evidenced by:
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Licensee to provide proof of association for S1 and S2, and to submit an Acknowlegement of Understanding regarding the said deficiency to LPA via emaill by POC due date.
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Based on LPA's observations, interviews, and review of records, S1 and S2 were not associated at the time of the visit which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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