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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336400166
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:49:15 PM

Document Has Been Signed on 08/17/2021 04:49 PM - 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: 3DATE:
08/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kelsea Rainwater - CaregiverTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20210811090734). During LPA Colvin's inspection, LPA Colvin observed additional items that needed to be addressed with the Licensee, Joseph Prior. Below is a summary of what was observed:

LPA Colvin received an email on 8/6/21 regarding resident (R1) being given a 30-day eviction notice. During today's visit, LPA Colvin inquired with the Licensee as to if they had a copy of the physical 30-day notice. LPA Colvin was informed that no physical notice had been provided to R1, but that R1 was given a verbal eviction notice, as well as his services coordinator through Inland Regional Center (IRC) and that R1 definitely is being evicted. LPA Colvin informed the Licensee that Title 22 Regulations require the facility to provide R1 with a written eviction notice. Deficiency cited. LPA Colvin requested for the facility to send her a copy of the eviction notice as well, once it has been provided to R1. Additionally, PA Colvin was informed that R1 has been missing from the facility for three days. LPA Colvin observed that no incident report had been sent to Licensing regarding the absence of R1. The facility has seven days from the date of the incident to submit a written report to Licensing, so LPA Colvin will be issuing a Technical Advisory Note, as the facility still has time to submit the report.

During today's inspection, LPA Colvin was unable to access staff files due to the files being kept in a locked cabinet. Neither the Licensee nor his business partner (who also has a key) were able to travel to the facility today to assist LPA Colvin with accessing the staff files. Deficiency cited.

An exit interview was conducted and a copy of this report along with LIC809D and appeal rights was provided during the exit interview with staff Kelsea Rainwater.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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 08/17/2021 04:49 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/17/2021 at 04:05 PM
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: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited
CCR
85068.5

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Eviction Procedures: (a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit for any of the following reasons:... This requirement was not met as evidenced by:
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Licensee agrees to provide R1 with a written eviction notice, in accordance with Title 22 Regulations. License to provide LPA Colvin with a copy of the eviction notice by Plan of Correction Date of 8/20/21.
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Based on interviews and record review, the Licensee did not comply with the above requirement. LPA Colvin observed that the Licensee did not provide R1 with a written eviction notice. This is a potential personal rights violation for R1.
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Type B
08/20/2021
Section Cited
CCR8066(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 agrees to formulate a plan to ensure that all records are available for Licensing to inspect at any time. Licensee to provide LPA Colvin with this plan and sefl-certification that it has been implemented by Plan of Correction date of 8/20/21.
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Based on interview and observations, the Licensee did not comply with the above regulation with all staff files. LPA Colvin was unable to access staff files due to no one present at the facility having access to the locked cabinet. This is a potential personal rights and safety risk to 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: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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