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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425640
Report Date: 07/09/2025
Date Signed: 07/09/2025 04:02:43 PM

Document Has Been Signed on 07/09/2025 04:02 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:QUALITY CARE ADULT HOME #1FACILITY NUMBER:
366425640
ADMINISTRATOR/
DIRECTOR:		HODGE, CHERYL RENEEFACILITY TYPE:
735
ADDRESS:12938 ARVILA DR.TELEPHONE:
(760) 245-5718
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 2DATE:
07/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Magdalena Ramirez-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit for health and safety in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office. LPA arrived and phone called Administrator, Magdalena Ramirez after knocking and ringing door bell three times. Administrator stated that she was on her way and would arrive shortly. LPA was then greeted by Administrator, Magdalena Ramirez. LPA introduced self and stated purpose of the visit.

During today's visit, LPA conducted observations, interviews with relevant parties, obtained and reviewed facility records, and did a walk-through of the facility. LPA found the following issues:
  • Staff 6 (S6) did not have first aid/cpr certification and worked alone with the clients during their shifts.
  • Staff 1 (S1) did not have criminal background clearance transfer to this facility by not being associated through Guardian.
  • Staff 1,3 & 4 (S1, S3 & S4) personnel records were incomplete.
  • S1 did not have the knowledge and ability to comply with applicable law and regulation.

These pose an immediate and potential health and safety risk to clients in care. Refer to LIC 809D, LIC421BG for deficiencies and civil penalty cited.

An exit interview was conducted where this report, LIC809D, LIC421BG and appeal rights were discussed with and provided to staff, Chandra Howard since Administrator left the facility.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Michelle Echeverria
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/09/2025 04:02 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/09/2025 at 02:57 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: QUALITY CARE ADULT HOME #1
FACILITY NUMBER: 366425640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2025
Section Cited
CCR
80075(f)

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80075(f) Health Related Services:
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
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Licensee stated that S6 will not be placed on the schedule without a first aid/cpr certified additional staff on shift until S6 obtains an approved first aid/cpr certification. Licensee stated that she will provide LPA with updated schedules by POC due date.
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Based on records review and interviews, the licensee did not comply with the section cited above by allowing S6 work without first aid/cpr certification which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
07/11/2025
Section Cited
CCR80065(i)(3)

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80065(i)(3) Personnel Requirements;
(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (3) Request and be approved for a transfer of a criminal record exemption...at the facility. This requirement is not met as evidenced by:
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Licensee stated that she will transfer and associate criminal background clearance of S1 to the facility and send proof to LPA via email by POC due date.
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Based on records review and interviews, the licensee did not comply with the section cited above by not transferring and associating S1 criminal background clearance which poses a potential health, safety or personal rights risk to persons 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/09/2025 04:02 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/09/2025 at 03:13 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: QUALITY CARE ADULT HOME #1
FACILITY NUMBER: 366425640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2025
Section Cited
CCR
80066(a)

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80066(a) Personnel Records:
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
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Licensee stated that she will have S1, S3 and S4 complete their records and send proof to LPA via email by POC due date.
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Based on records review and interviews, the licensee did not comply with the section cited above by not having S1, S3 and S4 complete their records which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/16/2025
Section Cited
CCR80064(a)(3)

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80064(a)(3) Administrator- Qualifications and Duties:
(a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement is not met as evidenced by :


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Licensee stated that she will hire a new Administrator and will provide proof to LPA by POC due date.
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Based on observations, records review and interviews, the licensee did not comply with the section cited above by making sure that the acting administrator had the knowledge to be able to comply with applicable law and regulations which poses a potential health, safety or personal rights risk to persons 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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Michelle Echeverria
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
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