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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004700
Report Date: 12/07/2023
Date Signed: 12/07/2023 10:42:30 AM


Document Has Been Signed on 12/07/2023 10:42 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 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:
12/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Maria Dolores- AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit in conjunction with the complaint investigation in connection to Complaint Control Number: 22-AS-20231101095717. LPA stated the purpose of the Case-Management-Deficiencies visit to Administrator (Admin) Maria Dolores.

On November 7, 2023, while conducting the complaint investigation mentioned-above, LPA observed the following violation:

Facility did not maintain the original records for Resident #1 (R1) following their termination of service.
Therefore, a deficiency is being cited per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D.

An exit interview was conducted with Administrator Maria Dolores, and a copy of this report including the LIC809-D, and 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: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
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 2


Document Has Been Signed on 12/07/2023 10:42 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 HOUSE #2
FACILITY NUMBER: 306004700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/14/2023
Section Cited
CCR
87506(e)

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87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
This requirement was not met as evidenced by:
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POC: Administrator stated that they will submit a proof of staff training and submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
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Based on observation and interviews, the facility did not maintain the original records for a minimum of three years following R1’s termination of service which poses a potential Health, Safety, and 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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2