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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336400166
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:31:13 AM

Document Has Been Signed on 03/01/2022 10:31 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:QUIROZ RESIDENTIALFACILITY NUMBER:
336400166
ADMINISTRATOR:SUSAN PRIORFACILITY TYPE:
735
ADDRESS:5926 QUIROZ DRIVETELEPHONE:
(951) 685-1061
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY: 6CENSUS: 1DATE:
03/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joseph Prior - LicenseeTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin and Licensing Program Manager (LPM) Joel Esquivel arrived at the facility unannounced for the purpose of conducting a health and safety check on the facility. LPA Colvin and LPM Esquivel met with Licensee Joseph Prior and advised them of the purpose of today's visit.

LPA Colvin conducted a tour of the facility and verified the current census of the facility (1 resident), though the resident is out at their work program. LPA Colvin did not observe any immediate health and safety concerns with the physical plant of the facility. LPA Colvin and LPM Esquivel additionally reviewed the current P&I money for the last remaining resident (R1) at the facility, as well as the P&I log where the incoming and outgoing funds are recorded. LPA Colvin observed that the P&I money for R1 did not reflect what was currently on the log. The Licensee has possession of a check for R1 that has not yet been cashed, but shows as cashed on the log. Additionally, the check was not in the resident's stored money, but in possession of the Licensee (to cash it). Deficiency cited. LPA Colvin observed in her review of the facility's file prior to today's inspection that the facility's annual fees are past due and have incurred a late fee. Deficiency cited. Additionally, Community Care Licensing (CCL) is looking into reported financial abuse of at least two (2) residents, for which CCL received incident reports for from the facility after CCL had been notified of the potential abuse by an outside party. These reports did not include a case number for law enforcement's investigation into the reported theft of the resident funds, and the Licensee has not submitted any proof to CCL or Inland Regional Center that this event was cross-reported to local law enforcement. Deficiency cited. LPA Colvin requested to view the personnel records for prior staff S1 & S2. Licensee produced file for S1, but not S2. Deficiency cited. This deficiency was additionally cited on 8/17/21 during a Case Management Inspection. Since this is the second time this deficiency has been cited in 12 months, LPA Colvin is assessing a civil penalty of $250 for repeat violation.
An exit interview was conducted and a copy of this report along with LIC809D, LIC421F, and appeal rights was provided during the exit interview with Licensee Joseph Prior.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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 03/01/2022 10:31 AM - It Cannot Be Edited


Created By: Crystal Colvin On 03/01/2022 at 09:59 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: QUIROZ RESIDENTIAL
FACILITY NUMBER: 336400166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
80026(h)(2)

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Safeguards for Cash Resources, Personal Property, and Valuables of Residents: (h) Each licensee shall maintain accurate records of accounts of cash resource...including, but not limited to the following: (2) Bank records for transactions of cash resources deposited in and drawn from the account specified...
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Licensee agrees to ensure records are updated and maintained. Licensee to submit proof of check deposit to LPA Colvin as well as current P&I log for R1 reflecting the deposit and check number. Plan of Correction due by 3/4/22.
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The Licensee did not comply with the above regulation with one resident (R1). LPA Colvin observed that R1's records for their P&I money included a check that was neither in the safe with the other funds nor cashed yet. This is a potential personal rights violation of R1.
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Type B
03/04/2022
Section Cited
CCR80066(e)

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Personnel Records: (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review. This requirement was not met as evidenced by:
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Licensee to submit staff file t to LPA Colvin for S2, including LIC501 Personnel Report. Plan of Correction due by 3/4/22.
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Based on record review, the Licensee did not comply with the above regulation with one staff (S2). LPA Colvin observed that no records were availbable at the facility for prior staff, S2, which LPA Colvin needs to review. This poses a potential personal rights risk to all residents 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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2022 10:31 AM - It Cannot Be Edited


Created By: Crystal Colvin On 03/01/2022 at 09:30 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: QUIROZ RESIDENTIAL
FACILITY NUMBER: 336400166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
80036(a)

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Licensing Fees: (a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement was not met as evidenced by:
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Licensee agrees to pay the current fees due and submit a statement of understanding to LPA Colvin for the need to pay all fees on time. Plan of Correction due 3/4/22.
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Based on record review, the Licensee did not comply with the above regulation with one license. LPA Colvin observed that the Licensee owes the Department $681.00 for their annual fee plus a late fee. Not having this paid is a potential safety risk to residents in care, as the license can be revoked.
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Type B
03/04/2022
Section Cited
CCR80065(m)

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Personnel Requirements: (m) All personnel shall be instructed to report observations or evidence of violations of any of the personal rights specified in Section 80072 and/or any of the personal rights provisions of Chapters 3 through 7. This requirement was not met by:
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Licensee to provide LPA Colvin with a case number for local law enforcement for investigation or report of financial abuse of R1 & R2. Plan of Correction due by 3/4/22.
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Based on record review, the Licensee did not comply with the above regulation with at least two residents (R1 & R2). LPA Colvin has not recieved any proof that the Licensee reported the suspected financial abuse of R1 & R2
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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