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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700978
Report Date: 04/16/2025
Date Signed: 04/16/2025 04:04:19 PM

Document Has Been Signed on 04/16/2025 04:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:QUARTER HOUSE, LLCFACILITY NUMBER:
392700978
ADMINISTRATOR/
DIRECTOR:		CAMPBELL, SCOTT R.FACILITY TYPE:
735
ADDRESS:2111 LIVINGSTON LANETELEPHONE:
(209) 351-4808
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 4DATE:
04/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Christin HuertaTIME VISIT/
INSPECTION COMPLETED:
04:15 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
Licensing Program Analyst’s (LPAs) Micheal Bilger and Noel Wolf Petersen arrived unannounced for a Case Management regarding two incident reports on 4/16/25. LPAs met with the assistant administrator and explained the purpose of the visit, and the administrator was informed of the presence of licensing.

First significant incident report:

On March 10th 2025 at 5 pm, Staff 1(S1) observed that three medications for Resident 1(R1) were unadministered as prescribed. Upon discovering the medication discrepancy S1 reported the error to the assistant administrator and administrator. The prescribing doctor was contacted for instructions regarding the missed doses. S1 was on the shift where the medication error occurred. S1 acknowledges the error in administering the medication. S1 has Direct Support Personnel 1&2 certification, training specific to medication dispersal prior to the error, and no previous incidents of medication procedure errors in the past year. The administrator reported the incident to CCL and regional center 3/10/25.

LPA has observed that medication training for S2 has taken place since the incident, and all clients MAR logs and bubble pack medication doses are currently in order.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: QUARTER HOUSE, LLC
FACILITY NUMBER: 392700978
VISIT DATE: 04/16/2025
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
26
27
28
29
30
31
32
Second incident report:

On 3/11/25, R1’s mother contacted the facility to collect some belongings, while gathering items the assistant administrator found a white Ziploc bag of white powdery substance. the assistant administrator called the non emergency police number to remove the substance, generating a police report 25-7303. The police did not update with an identity for the substance since. The assistant administrator scheduled a meeting with R1’s regional center service coordinator to discus and review safety protocols. R1 was reminded the house rule regarding substances, that the police may be called.

LPA asked to review the needs and services plan, house rules, and admission agreement, R1 is permitted to leave unassisted, he does have a substance abuse and depression for medical history, and the facility plans on having an Interdisciplinary Team (IDT) meeting with the resident every month for a period of time that it takes for the behavior to be addressed. LPA asked for an IPP regarding the client.

As the facility is not in compliance regarding eminent risks to the health or safety of the residents in their care regarding these incidents, a citation was issued for Section 80075 (b) pursuant to title 22, noted on 809-D.

A copy of the report, and appeal right was read and given to the assistant administrator.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/16/2025 04:04 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 04/16/2025 at 03:45 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: QUARTER HOUSE, LLC
FACILITY NUMBER: 392700978

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2025
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075 health related services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
1
2
3
4
5
6
7
The facility did a live training with S1 and additional staff recived a video training on 3/12. Licensee to submit a copy of the training by april 17th.

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

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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4