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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881377
Report Date: 07/03/2023
Date Signed: 07/03/2023 10:09:31 AM

Document Has Been Signed on 07/03/2023 10:09 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:QUALITY CARE ONE LLCFACILITY NUMBER:
331881377
ADMINISTRATOR:LEE, DANIELLEFACILITY TYPE:
735
ADDRESS:24021 PUDDINGSTONE DRTELEPHONE:
(323) 551-7326
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92551
CAPACITY: 2CENSUS: 0DATE:
07/03/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Applicant Danielle LeeTIME COMPLETED:
10:15 AM
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On Monday, 7/3/2023, at 9:00 a.m., Licensing Program Analyst (LPA) Janette Romero conducted an announced visit to the pending facility to conduct a pre-licensing inspection. LPA met with Applicant Danielle Lee. Fire clearance has been granted for (2) clients. Applicant Lee’s Administrator certificate expires on 2/12/2025.

LPA conducted of a tour of the facility’s interior and exterior. Facility is made up of 2 client bedrooms and 1 client bathroom along with a kitchen, living/family room, and garage. LPA did not observe bodies of water. The physical plant was in good repair. Outside self-closing gate latch is in disrepair. Outdoor passageways are not free of obstructions; however, Applicant Lee stated some of the items are garbage and will be disposed of this week. Outside area of the facility has a shaded area with available seating. LPA observed a charged fire extinguisher, operating smoke alarms, carbon monoxide detectors, and a working telephone. LPA observed a locked area for cleaning solutions, medications, and knives/sharp instruments.

LPA toured the bedrooms. Client bedrooms had the required bedding, furniture, and functional lighting. Additional linen and towels are available for clients. LPA observed new hygiene kits in client bedrooms. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility met the 2-day supply of perishable food and 7 day supply of nonperishable food items. Facility had emergency food and water stored in a closet near the entrance. Client and staff files will be secured in a file cabinet in the garage.

Continued on LIC809-C..
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: QUALITY CARE ONE LLC
FACILITY NUMBER: 331881377
VISIT DATE: 07/03/2023
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LPA toured the bathroom. Bathroom is missing grab bar and non-slip mat in the shower. The hot water temperature in client bathroom measured at 129.7 degrees Fahrenheit.

Emergency disaster plans, personal rights, and complaint procedures were posted in living/family room wall. LPA observed two complete first aid kits. Living/family room has a working television and adequate seating in common areas.

The following corrections are needed prior to licensure:

1. Install grab bar in client shower

2. Provide non-slip mat in client shower

3. Repair/replace self-closing gate latch

4. Clear outside passageways from obstructions

5. Adjust hot water temperature in client bathroom to be within 105 – 125 degrees Fahrenheit

Applicant stated proof of corrections will be submitted to LPA by close of business on Monday, 7/10/2023.

An exit interview was conducted where a copy of this report was discussed and provided to Applicant Lee.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023
LIC809 (FAS) - (06/04)
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