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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600188
Report Date: 07/18/2024
Date Signed: 07/18/2024 06:54:01 PM

Document Has Been Signed on 07/18/2024 06:54 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:AQUINO'S QUALITY HOMECAREFACILITY NUMBER:
374600188
ADMINISTRATOR/
DIRECTOR:		FELICIDAD M. AQUINOFACILITY TYPE:
735
ADDRESS:598 IVY COURTTELEPHONE:
(619) 482-6897
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 6CENSUS: 6DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Caregiver Angelito Monzon and Licensees Bernard and Felicidad AquinoTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Angelito Monzon. LPA then met and spoke with Licensees Bernardo and Felicidad Aquino, who arrived later during the visit.

According to the facility’s license, the facility has a maximum capacity for six (6) clients, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LPA observation, staff interviews, and review of clients’ LIC602 Physician’s Report: During today’s visit, there were a total of six (6) clients in care, of whom one (1) was non-ambulatory, five (5) were ambulatory, and none were bedridden. This facility’s license does not include endorsements for secured perimeter or delayed egress doors, and none of these were present during the visit.

During today’s visit, LPA interviewed multiple staff and clients. LPA reviewed all staff and resident records/files. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in general good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 07/18/2024 06:54 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/18/2024 at 03:12 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AQUINO'S QUALITY HOMECARE
FACILITY NUMBER: 374600188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, for 5 of 5 staff (S1 through S5), Licensee did not ensure that they were trained in the proper use of all required PPE prior to being around clients and annually thereafter. This posed a potential health risk to 6 of 6 clients (C1 thorugh C6) in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to contact San Diego County's public health agency (619-692-8499) to coordinate training for S1 through S5 on how to correctly don and doff PPE, among other infection control topics. (If the public health agency is not responsive, Licensee agreed to have an alternate licensed nurse lead the training). Licensee agreed to E-mail a copy of the training sign-in sheet (which will also list the trainer's full name and credentials) to LPA, by the POC due date.
Type B
Section Cited
CCR
85095.5(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 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, Licensee did not maintain an Infection Control Plan as part of the facility's Plan of Operation. This posed a potential health risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to complete CCLD form LIC9282 Residential Infection Control Plan. Licensee agreed to also train its current staff on this plan. Licensee agreed E-mail both the LIC9282 and the trianing sign-in sheet to LPA, by the 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/18/2024 06:54 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/18/2024 at 03:12 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AQUINO'S QUALITY HOMECARE
FACILITY NUMBER: 374600188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075.4(a)
Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: The Licensee did not ensure that 6 of 6 clients (C1 through C6) were regularly observed for changes in physical functioning, specifically weight gain/loss. This posed a potential health risk to persons in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to measure and log the body weights of R1, R2, and R3, and to E-mail copies of these logs to LPA, by the POC due date. Going forward, Licensee agreed to weigh each client in care once per month, and to record/log the weight in writing in the client's care binder.
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, records review, and staff interviews, for 4 of 5 staff (S1 through S4) who assist clients with inhalers and who themselves were not licensed professionals, Licensee did not maintain written documentation that these staff had been trained on inhaler use/procedures. This posed a potential health and safety risks to persons in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to have S1 thorugh S4 trained on inhaler use/procedures by a licensed professional (such as a licensed nurse). The training will include a skills demonstration component. Licensee agreed to submit the training sign-in sheet (which will indicate the trainer's full name and credentials) and any handouts used to LPA, by the 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/18/2024 06:54 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/18/2024 at 03:12 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AQUINO'S QUALITY HOMECARE
FACILITY NUMBER: 374600188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)2
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 2. The licensee ensures that the licensed professional reviews staff performance as the licensed professional deems necessary, but at least once a year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, for 4 of 5 staff (S1 through S4) who assist clients with inhalers and who themselves are not licensed professsionals, Licensee did not ensure that a licensed professional reviewed staff reviewed their performace on inhalers at least once per year. This posed a potential health and safety risk to persons in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to have S1 thorugh S4 trained on inhaler use/procedures by a licensed professional (such as a licensed nurse). The training will include a skills demonstration component. Licensee agreed to submit the training sign-in sheet (which will indicate the trainer's full name and credentials) and any handouts used to LPA, by the POC due date. Going forward, Licensee agrees to ensure that the licensed professional reviews staff performance on inhalers at least once per year.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, Licensee did not maintain an Emergency and Disaster Plan for the facility which meets current regulatory requirements. This posed a potential safety risk to 6 of 6 clients (C1 through C6) in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to complete CCLD form LIC610D Emergency and Disaster Plan for Adult Community Care Facilities. Licensee agreed to also train its current staff on this plan. Licensee agreed E-mail both the LIC610D and the trianing sign-in sheet to LPA, by the 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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/18/2024 06:54 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/18/2024 at 03:12 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AQUINO'S QUALITY HOMECARE
FACILITY NUMBER: 374600188

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on records review and staff interview: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift. This posed a potential safety risk for 6 of 6 clients (C1 through and C4) in care.
POC Due Date: 08/18/2024
Plan of Correction
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Licensee agreed to perform one (1) emergency/disaster drill each on the morning AM shift (6:00 AM to 2:00 PM), the PM shift (2:00 PM to 10:00 PM) and the overnight NOC shift (i.e., 10:00 PM to 6:00 AM), and to document the results of these drills in writing. Licensee agreed to E-mail proof of drills completion, by the POC due date. Going forward, Licensee agreed to perform an emergency/disaster drill at least quarterly for each shift.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


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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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: AQUINO'S QUALITY HOMECARE
FACILITY NUMBER: 374600188
VISIT DATE: 07/18/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility’s ambient internal temperature was complaint at 73 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen Sink was 112.3 F, Bathroom #1 Sink was 112.1 F, and Bathroom #2 Sink was 111.7 F. Appliances to preserve perishable food were also compliant in temperature: Kitchen Refrigerators were both 39 F, and Kitchen Freezers were both 0 F, respectively. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detector, smoke detectors, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond.

During records review, LPA observed, and staff interviews confirmed: Licensee did not have records of body weights for Client #1 (C1) through Client #5 (C5). For Client #6 (C6), the last body weight which Licensee had for them was from April 2023. (Regulation requires Licensees to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.”) [See LIC811 Confidential Names List for a description of person identifiers used in this report.] Medication lists and staff interviews showed that C2 and C3 were both prescribed medications delivered by inhalers. However, Licensee did not maintain proof that four (4) of five (5) facility staff [Staff #1 (S1) through Staff #4 (S4)] who assisted clients with inhalers were trained on such devices by a licensed professional, as was required. Licensee also did not maintain proof that a licensed professional reviewed/evaluated these staff’s performance on inhalers at least once per year, as was required.


[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: AQUINO'S QUALITY HOMECARE
FACILITY NUMBER: 374600188
VISIT DATE: 07/18/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

During today’s visit, LPA saw that supplies of Personal Protective Equipment (PPE) were present on-site. However, Licensee did not maintain proof that S1 through Staff #5 (S5) were trained on the correct use of PPE within the last year, as was required. Records show, and staff interviews confirmed: While Licensee indeed performed multiple disaster drills every year over the last few years, they were less frequent than quarterly, and they did not include drills on the overnight “NOC” shift (from 10:00 PM to 6:00 AM). (Regulation required each shift to be drilled at least once per quarter). During today’s visit, LPA requested, but Licensee was unable to produce the written Infection Control Plan for the facility. Licensee confirmed that they also did not have an updated LIC610D Emergency Disaster Plan for the facility which fully meets the current regulatory requirements.

Five (5) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA issued one (1) Technical Violations (TV) regarding proof of current First Aid Training for S4 (refer to the attached LIC9102-TV page). LPA also provided Technical Assistance (TA) regarding obtaining updated medical assessments for R1 and regarding additional night lights (refer to the attached LIC 9102-TA pages).

An exit interview was conducted with the Aquinos, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, LIC9102-TA pages, the LIC811 Confidential Names Lists, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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