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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880903
Report Date: 06/15/2022
Date Signed: 06/15/2022 10:20:04 AM

Document Has Been Signed on 06/15/2022 10:20 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
, CA 92507
FACILITY NAME:HOPE QUALITY CARE SERVICESFACILITY NUMBER:
361880903
ADMINISTRATOR:DAVALOS, RHEAFACILITY TYPE:
735
ADDRESS:1485 MONTE VERDE AVETELEPHONE:
(909) 697-9843
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 6CENSUS: 0DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Rhea DavalosTIME COMPLETED:
10:29 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic.

LPA Gardner met with Administrator Rhea Davalos who confirmed that there are currently no cases and or exposures of COVID-19 within the facility. At the time of visit there was one (1) staff, one (1) non-client resident, and zero (0) clients present. The facility is currently waiting on placement from Inland Regional Center.

LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Rhea Davalos. LPA Gardner observed all staff members with a properly fitted face covering. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The client rooms have hand sanitizer, and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for proper cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the front entry closet. The facility has a full thirty (30) day supply of PPE items such as gloves, face shields, gowns, N95 masks, disinfectant, and hand sanitizer.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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 06/15/2022 10:20 AM - It Cannot Be Edited


Created By: Ryan Gardner On 06/15/2022 at 09:53 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
, CA 92507

FACILITY NAME: HOPE QUALITY CARE SERVICES
FACILITY NUMBER: 361880903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
80019. Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing the non-client resident (NCR) to live in the facility for (2) two years without completing a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2022
Plan of Correction
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The licensee has agreed to remove the non-client resident (NCR) from the facility. The licensee has agreed to not allow the non-client resident (NCR) in the facility until they complete the criminal background clearance. The licensee has agreed to read regulation 80019 entirely and send LPA self-certify letter that the regulation was read and understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HOPE QUALITY CARE SERVICES
FACILITY NUMBER: 361880903
VISIT DATE: 06/15/2022
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All staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

During today’s visit, LPA Gardner found that one (1) non-client resident (NCR) was not background cleared to be at the facility. The non-client resident (NCR) has been living at the facility for two (2) years.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. The facility will be receiving a $500 civil penalty for the citation.

An exit interview was conducted, and this report was discussed and provided to Administrator Rhea Davalos along with a copy of LIC-811, LIC-809D, LIC-421BG, and the appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
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