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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425640
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:34:46 PM

Document Has Been Signed on 06/23/2023 12:34 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:HODGE, CHERYL RENEEFACILITY TYPE:
735
ADDRESS:12938 ARVILA DR.TELEPHONE:
(760) 245-5718
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 5CENSUS: 2DATE:
06/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Regina Scott-AdministratorTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. LPA arrived at the facility to conduct a case management visit to follow up on a client's death. LPA met with Staff Jasmine Scott and explained the purpose of the visit. Administrator Regina Scott later arrived and was informed of the purpose of the visit.

The case management visit consisted of a walk through of the facility, collection of client documents and interviews regarding the events which led to the client's death. LPA interviewed the Administrator for further information regarding the death of C1 and the events that led up to C1's death. Administrator stated that no official death certificate has been received at this time, yet she was informed by the hospital about the preliminary cause of death. LPA has advised the Administrator to send a copy of the death certificate to the Community Care Licensing Division (Department) Riverside Regional Office as soon as it is available. LPA spoke to C1’s conservator on the telephone during today’s visit, LPA was provided the cause of death based on what they were told by the hospital and what was printed on the death certificate. LPA informed C1's conservator to provide a copy of the death certificate via email to LPA.

During record review, LPA observed missing incident reports. Deficiency issued.

Deficiency was cited during this visit. An exit interview was conducted where this report LIC 809, LIC809D and appeal rights were discussed and provided to Administrator Regina Scott.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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 06/23/2023 12:34 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/23/2023 at 11:48 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: QUALITY CARE ADULT HOME #1
FACILITY NUMBER: 366425640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency....occurrence of such event. This requirement is not met as
evidenced by:
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Administrator stated that she will hold a meeting with staff and review regulation 80061(b) and submit proof of attendance meeting to LPA via email by POC due date.
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Based on observation, interview, and record review the Administrator did not comply with the section cited above by not reporting the occurrence of incidents which poses a
potential health, safety and 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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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