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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006179
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:05:30 AM

Document Has Been Signed on 10/05/2023 11:05 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:FOOTHILL RESIDENTIAL CAREFACILITY NUMBER:
306006179
ADMINISTRATOR:QUEZADA, JOSHUAFACILITY TYPE:
735
ADDRESS:8404 E FOOTHILL STTELEPHONE:
(562) 756-6463
CITY:ANAHEIMSTATE: CAZIP CODE:
92808
CAPACITY: 4CENSUS: 3DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Joshua QuezadaTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA arrived at the facility, rang the doorbell and knocked on the door. After receiving no response, LPA walked the perimeter of the facility and did not observe anyone present. LPA contacted Licensee Malia Quezada by phone and explained the purpose of the inspection. Administrator (AD) Joshua Quezada was contacted and arrived at 9:15 a.m. During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with three client bedrooms and two bathrooms. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA did not observe any clients present at the facility, as all were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 120.1 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Appliances were all inspected. Sharps were observed locked in a kitchen cabinet. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed three out of three client files and observed all three files were missing a Physician Report (LIC602); a Deficiency was cited on today's date. LPA reviewed two staff files and observed both files were missing Health Screenings (LIC503); a deficiency was cited on today's date. Clients were not present to be interviewed.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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 10/05/2023 11:05 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 10/05/2023 at 10:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FOOTHILL RESIDENTIAL CARE
FACILITY NUMBER: 306006179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two out of two personnel records, which poses a potential health, and personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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AD stated they would obtain maintain health screening reports for all personnel/records and provided LPA with a copy via email by POC date.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in three out of three client filies, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 10/03/2023
Plan of Correction
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AD stated they would obtain and maintain medical assessments for all clients and provide LPA with a copy via email 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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