366426555-9-11-2023-56-AS-MECA-CVL3R3-20230911182805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426555
Report Date: 09/11/2023
Date Signed: 09/11/2023 06:28:16 PM

Document Has Been Signed on 09/11/2023 06:28 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:	APPEARANCE QUALITY HOME		FACILITY NUMBER:	366426555
ADMINISTRATOR:	RILEY, RACHEL		FACILITY TYPE:	740
ADDRESS:	10752 OAKWOOD AVE.		TELEPHONE:	(760) 956-2800
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 6	DATE:	09/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Rachel Riley-Administrator		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/11/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Blanca Cabrera, and introduced self and stated purpose of the visit. LPA was informed that there are currently 6 residents in care. The facility has 6 bedrooms, 3 bathrooms, kitchen, dining area, living room, office, attached garage, and backyard. LPA completed a walk through of facility and review of records. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 108.3 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguishers and emergency kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed the emergency disaster plan not reviewed since April 2022. Deficiency issued. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated locked storage space for resident/staff files and medication. Food Service: Non-perishable and perishable food supply is not sufficient for number of residents in care. LPA observed lots of expired perishable and nonperishable food. Deficiency issued. Dishes, cups, and utensils were also stored properly.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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 09/11/2023 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME	FACILITY NUMBER: 366426555
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above in not providing criminal record clearance of (S2) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will remove (S2) from schedule and follow up with (S2) and Guardian to get approval clearance on her in process status. Administrator will provide proof of clearance to LPA via email once it is approved.

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the administrator did not comply with the section cited above in maintaining one week of nonperishable and two days of perishable foods for residenst in care after disposing the expired nonperishable and perishable food which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will replenish one week of nonperishable and two day of perishable foods and provide proof of receipt and pictures to LPA via email by POC due date. Administrator stated that she will conduct a staff training and submit proof to LPA via email.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2023 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME	FACILITY NUMBER: 366426555
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in providing an Infection Control Plan in the facility file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will create and submit an Infection Control Plan to LPA via email by POC due date.

Type B

Section Cited

CCR

87412(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:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, administrator did not comply with the section cited above in maintaining complete personnel records for (S1) and (S2) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will have (S1) and (S2) complete and sign all required forms for their personnel records. Administrator stated that she will submit proof to LPA via email by POC due date.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2023 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME	FACILITY NUMBER: 366426555
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in providing proof of training, first aid/cpr certification, and medication training for staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will have staff complete required training along with first aid/cpr and medication training and submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete resident records for (R1) like the physician's report and appraisal/needs & services which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will complete (R1) resident records and submit proof to LPA via email by POC due date.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2023 06:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME	FACILITY NUMBER: 366426555
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in reviewing annually the emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will submit the updated emergency disaster plan and submit proof to LPA via email by POC due date.

Type B

Section Cited

CCR

87705(l)(1)

Care of Persons with Dementia

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above in notifying the licensing agency of their intention to lock the exterior door/gate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will submit a request of their intent to lock the exterior door/gate to the licensing agency by POC due date via certified mail and submit a copy to LPA via email.

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	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME	FACILITY NUMBER: 366426555
	VISIT DATE: 09/11/2023

NARRATIVE

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Yards/Outside: One shaded patio, a side gate with a locked door knob on the right side of the house that leads into the backyard, a shed and industrial container used as storage. Deficiency issued for locked gate due to not notifying the licensing agency. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Not all staff members working in the facility have criminal record clearance through the department. Deficiency issued with civil penalty.

Record Review: LPA reviewed 4 resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed an incomplete resident file for resident 1 (R1). Deficiency issued. LPA also reviewed administrator's and 4 staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed incomplete personnel records for (S1) (S2) and (S3). Deficiency issued. LPA also observed missing trainings for first aid/cpr and medication for staff. Deficiency issued. LPA observed that the facility did not have an Infection Control Plan. Deficiency issued.

Eight deficiencies and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to the Administrator Rachel Riley who later arrived.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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