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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702010
Report Date: 08/25/2021
Date Signed: 12/13/2022 08:37:35 AM


Document Has Been Signed on 12/13/2022 08:37 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, 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:
08/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:DOROTHY QUEJA TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Diaz conducted an unannounced visit to the facility and was met at the facility by Dorothy Queja, the owner/licensee. LPA explained the reason for the visit. A tour of the interior and exterior premises of the facility was conducted. The facility's premises are found to be very clean, well-organized, sanitary, free of undesirable odors, and very well maintained. LPA observed alarms on the front door, and two alarms on the outside fences. 6 emergency alarm exists for the resident’s bedroom.

On 8/22/21, around 12:00am The Police arrived at the facility stating the resident was found wandering the streets. The Licensee stated that they neglected to lock the laundry room door and the resident left the facility through the side door/laundry room. The laundry room door did not have an alarm installed. There are two exists that lead outside from the laundry room door and both exist contained alarms with dead batteries. The resident was found not injured and stayed the rest of the night with family but returned to the facility the next morning at 1130am. LPA observed 2 newly installed alarms on the laundry room door and on the door entrance of the resident’s room. LPA also observed new batteries for the two exit doors that lead outside from the laundry room.

The licensee failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on an LIC 809-D.

An Exit interview conducted, deficiency cited, and a copy of this report and appeal rights were emailed to Licensee for signature and return.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021
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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Document Has Been Signed on 12/13/2022 08:37 AM - 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: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2021
Section Cited

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87468.1 (A)(4) Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have the following personal rights: (4) To care, supervision, and services that meet their individual needs and delivered by staff that are sufficient, qualifications, and competent to meet needs.
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Administer agreed to immediately install additional alarms to the laundry room door and replace door exit alarms with new batteries by 8/25/21. LPA observed additional laundry room door alarm and new batteries for the door exits.
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Based on the Licensee’s statement, the licensee did not lock the laundry room door and R1 was AWOL
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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: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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