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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700611
Report Date: 06/14/2022
Date Signed: 06/14/2022 10:31:08 AM

Document Has Been Signed on 06/14/2022 10:31 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:QURESHI CARE HOMEFACILITY NUMBER:
392700611
ADMINISTRATOR:UMER QURESHI, MUHAMMADFACILITY TYPE:
735
ADDRESS:9555 PRISCILLA LANETELEPHONE:
(209) 565-5258
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 5CENSUS: 5DATE:
06/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Umer "Ali" Qureshi, AdministratorTIME COMPLETED:
10:45 AM
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On 06/14/2022 at 9:30 AM Licensed Program Analysts (LPA) T. White arrived unannounced to conduct a case management visit regarding incident report submitted to CCLD on 03/31/2022. LPA met with Administrator, Umer "Ali" Qureshi and explained the purpose of the visit.

Based on incident report, staff noticed a bump on Client #1 (C1) buttocks region after C1 got out the shower. House manager and Administrator were notified. C1 was taken to the emergency room and diagnosed with a pressure ulcer and prescribed antibiotics.

Based on documentation, Home Health Nurse arrived on 04/05/2022 to assess C1's wound and diagnosed wound as a stage 2 ulcer. Based on report, Home Health agency will send a nurse for the first 14 days to clean and treat C1's wound with the proper dressing and 3 times a week thereafter once wound is showing signs of closing. LPA observed C1's written plan of care to ensure wound does not advance and Individual Program Plan (IPP) Addendum. Based on Administrator, C1's wound is now closed based on verbal confirmation from Nurse on 06/03/2022. Administrator stated he will request nurse notes and submit to CCLD once received.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were observed.

Exit interview conducted with Administrator, copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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