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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003556
Report Date: 09/23/2021
Date Signed: 09/23/2021 01:39:33 PM

Document Has Been Signed on 09/23/2021 01:39 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:QUALITY ADULT CARE HOME IIFACILITY NUMBER:
347003556
ADMINISTRATOR:HARRIS, VALERIE L.FACILITY TYPE:
735
ADDRESS:5701 LERNER WAYYTELEPHONE:
(916) 391-0363
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Terrance Harris, Administrator.
TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Caregiver S1, Desiree Lewis. LPA met with Terrance Harris, Administrator.

LPA and S1, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas. LPA inspected backyard. Backyard was free and clear of debris.
LPA observed laundry room cabinets worn down knobs were falling off cabinets, wallpaper torn peeling from wall, water spots throughout wall.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 109.4 degrees in residents bathroom with the S1 which is in required range of 105 to 120 degrees.
Last Fire Drill conduced dated 9/15/21. Fire extinguisher maintained 8/23/2021.
Fire alarm and carbon monoxide functional. LPA and AD observed centrally stored medications. LPA observed sharps and toxins locked.
LPA reviewed 6 staff and 6 resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. Administrator Certificate valid until 12/11/2022.
All persons in facility fully vaccinated with exception of 2 staff due to personal reasons. LPA observed 30 days PPE supply.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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 09/23/2021 01:39 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 09/23/2021 at 11:49 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: QUALITY ADULT CARE HOME II
FACILITY NUMBER: 347003556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement has not been met as evidenced by:
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LPA observed laundry room cabinets worn, cabinet knobs are falling off the doors, wallpaper falling off the walls, and water stains throughout. LPA observed multiple cracked tiles throughout kitchen and laundry room.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021


LIC809 (FAS) - (06/04)
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