<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700611
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:24:47 PM

Document Has Been Signed on 06/27/2022 03:24 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, 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:
06/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Umer "Ali" Qureshi, AdministratorTIME COMPLETED:
03:35 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 06/27/2022 at 2:30 PM, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a case management visit regarding medications. LPA met with Adminstrator, Umer "Ali" Qureshi, and explained the purpose of the visit.

LPA reviewed 5 clients Medications Administration Records (MARs). Based on documentation, 4 of 5 clients medications were missed on 06/25/2022 and 06/26/2022. 1 of 5 clients medications was missed only on 06/26/2022. Based on clients bubble pack medications, medications were administered on 06/25/22022 and 06/26/2022. LPA interviewed 4 staff members. 4 of 4 staff stated clients medications were administered on time. However, Staff #5 (S5) did not sign the MARs to show clients received their medication.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and appeal rights 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
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 2
Document Has Been Signed on 06/27/2022 03:24 PM - It Cannot Be Edited


Created By: Treana White On 06/27/2022 at 12:50 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: QURESHI CARE HOME
FACILITY NUMBER: 392700611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2022
Section Cited
CCR
80075(b)(5)(C)

1
2
3
4
5
6
7
80075(b)(5)(C): Health Related Services: (b) Clients shall be assisted as needed...(5)If the client's physician has stated in writing...(C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to conduct in-service training with all staff regarding medications. Administrator agreed to submit proof to CCLD by POC date.
8
9
10
11
12
13
14
Based on documentation, facility did not comply with the section 80075(b)(5)(C). LPA observed missed documentation on 5 of 5 Medication Administration Records, showing clients did not receive medication on 06/25/2022 and 06/26/2022 which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2