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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702010
Report Date: 10/05/2022
Date Signed: 10/05/2022 06:51:17 PM


Document Has Been Signed on 10/05/2022 06:51 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:QUEJA RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
421702010
ADMINISTRATOR:QUEJA, DOROTHYFACILITY TYPE:
740
ADDRESS:845 PATTERSON ROADTELEPHONE:
(805) 934-3702
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
10/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Dorothy Queja, Administrator/LicenseeTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 10/05/2022 around 2:15 PM. LPA met with Dorothy Queja, Licensee/Administrator around and explained the purpose of the visit.

LPA took a physical plant tour of the facility with Administrator. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. The staff will screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff willwear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed.

The Administrator is in charge of infection control and provides training and education to staff, residents and visitors.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: QUEJA RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 421702010
VISIT DATE: 10/05/2022
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Staff will use full PPE with N95 masks and face shields when around with any pending or confirmed cases of Covid-19. The facility has single rooms that are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.

Facility will conduct training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked office. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance.

Administrator Certificate is valid. Fire extinguishers were charged and inspected annually, Smoke and carbon monoxide detectors were present and working.

At approximately 4:00 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined that all staff are fingerprint cleared and associated to the facility

At approximately 2:15 PM LPA Olson observed Licensee and 2 staff in the facility with no masks

LPA also observed Facility did not submit multiple Incident reports (LIC 624 and LIC 624A) for at least one resident.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D).



Exit interview completed and copy of report, Deficiencies, and appeal rights emailed to Administrator /Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/05/2022 06:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: QUEJA RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 421702010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 (a)(2) Personal Rights of Residents in all Facilities; To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 staff were not wearing masks in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Administrator agreed to immediately implement mask wearing in the facility. Conduct training on Mask/Infectious Disease Prevention with all staff. Provide training records with all staff signatures to CCL by 10/6/2022.
Type A
Section Cited
CCR
87211(a)(1)
87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure incident reports were sent within 7 days of the occurrence on multiple occasions, which posed a potential health, safety, and personal rights risk to residents in care.
POC Due Date: 10/10/2022
Plan of Correction
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The Administrator agreed to do the following:
Review Regulation 87211 and submit a Statement of Understanding, detailing how the licensee plans to maintain voluntary compliance. Submit statement no later than 10/10/22.

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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
LIC809 (FAS) - (06/04)
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