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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881377
Report Date: 07/31/2024
Date Signed: 07/31/2024 10:03:26 AM


Document Has Been Signed on 07/31/2024 10:03 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 ASC, 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:
07/31/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee Danielle LeeTIME COMPLETED:
10:07 AM
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Licensing Program Analyst (LPA) Valerie Flores and Licensing Program Manager (LPM) Rikesha Stamps conducted an announced annual required visit. LPA and LPM were granted entry and conducted a tour of the exterior and interior of the facility with Licensee Danielle Lee. The facility is licensed for a capacity of two (2) resident whom may be ambulatory only. There are currently no residents in care and Licensee is awaiting Inland Regional Center (IRC) client placement. Staff working at the facility have obtained proper fingerprint clearance and association to the facility. LPA observed the following during the tour:

During the tour of the facility, LPA and LPM observed that the facility is made up of two (2) bedrooms and one (1) bathroom for clients in care, large backyard, a kitchen, living room, and garage. Clients bedrooms were equipped with the required bedding, furniture, and functional lighting. Additional linen and towels are available for clients and appear to be in good repair. LPA did not observe no pools or bodies of water. Per Licensee Danielle, there are no firearms or ammunition on the premises. The facility met the 2-day supply of perishable food and 7-day supply of nonperishable items.

The physical plant was in good repair. Indoor/outdoor passageways are free of obstructions. The outside of the facility has a shaded area with available seating. LPA and LPM observed a charged fire extinguisher near the entrance, operating smoke alarms, carbon monoxide detectors, and a working telephone. LPA and LPM observed a locked cabinets in the kitchen for cleaning solutions, knives and other sharp instruments. A separate locked cabinet was located in the kitchen for centrally stored medication. All staff and client files are going to be locked in an office located in the garage once clients are accepted into the facility. Fireplace was equipped with an appropriate covering.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: QUALITY CARE ONE LLC
FACILITY NUMBER: 331881377
VISIT DATE: 07/31/2024
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Emergency disaster plan and facility sketch was posted near the hallway of the facility. Near the entry door was posted the Long Term Care Ombudsman (LTCO), Facility License, and Personal Rights Posters. Facility records review include but are not limited to first-aid training, emergency disaster training, CPI, and CPR training and more.

An exit interview was conducted where a copy of this report was provided to Licensee Danielle.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Valerie FloresTELEPHONE: (951) 248-0308
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
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