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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700611
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:23:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220621150128
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:
06/27/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Umer "Ali" Qureshi, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff over medicating residents
INVESTIGATION FINDINGS:
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On 06/27/2022 at 9:30 AM, Licensing Program Analyst (LPA) T. White arrived unannounced to open and investigate complaint allegation noted above. LPA met with Umer "Ali" Qureshi, Administrator and explained the purpose of the visit. During course of investigation, LPA reviewed documents and medication. LPA interviewed 4 staff members and 3 clients.

LPA observed medications given according to the clients physician order. Based on clients bubble pack medications, medications have been administered in the month of June 2022. LPA observed no additional medications removed from the bubble pack. At 12:00 PM, LPA observed staff administering medications to clients. LPA did not observe staff over medicating clients. Based on 4 staff members interviews, 4 of 4 staff stated the clients are not over medicated. LPA attempted to interview 3 clients. Based on observation , it appeared 2 of 3 clients were unable to understand the questions asked. 1 of 3 clients stated she does not feel any new changes when medication is administered. LPA is unable to prove or disprove if allegation occurred.
Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220621150128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 392700611
VISIT DATE: 06/27/2022
NARRATIVE
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Based on interviews, observations and record review, it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator and a copy of report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2