480111474-7-18-2023-21-AS-DTOA-CTUQXL-20230718123342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 480111474
Report Date: 07/18/2023
Date Signed: 07/18/2023 12:33:59 PM

Document Has Been Signed on 07/18/2023 12:33 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	Q & Q FAMILY CARE HOME		FACILITY NUMBER:	480111474
ADMINISTRATOR:	QUINN, LONDA		FACILITY TYPE:	735
ADDRESS:	2717 TENNESSEE STREET		TELEPHONE:	(707) 644-5303
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY: 5		CENSUS: 3	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Londa Quinn, Licensee		TIME COMPLETED:	12:45 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 7/18/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Licensee, Londa Quinn and Lead Staff Adriane Johnson. The facility currently provides care for 3 clients, 2 of which were attending day program and one of which present in the facility at the time of visit. LPA informed that the clients attending day program are provided transportation directly from the facility throughout the week to attend program. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/9/2023. Smoke and carbon monoxide detectors were tested throughout the facility and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. All client’s bedrooms have lighting & appropriate furnishings with bedrooms well maintained and cleaned by staff. LPA toured the backyard and observed a storage shed that was found to be secure and emergency exit was unobstructed. Water was tested at faucets accessible to clients and measured 109.8 degrees F which falls within Title 22 regulation. Sharps, cleaning supplies and other items that could pose harm if accessible to client in care were found to be secured in the kitchen areas and are inaccessible to clients with staff supervising in the common area. Medications are located in a designated cabinet located in the hallway with administering and prescription records in order. Upon review of medications, LPA found that facility properly administers and records medication on the Medication Administration Record (MAR). However, facility does not have current Centrally Stored Medication Record (CSMR) indicating new prescription orders and start dates. Continued onto LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: Q & Q FAMILY CARE HOME	FACILITY NUMBER: 480111474
	VISIT DATE: 07/18/2023

NARRATIVE

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LPA conducted a sample file review for staff and found staff to have 1st Aid & CPR training up to date. Upon review of staff training, LPA found that all staff have a sufficient number of hours of annual training completed. LPA also conducted a file review for all clients and found medical documentation up to date. However, LPA found that clients (C1, C2 & C3) require an updated Needs & Service Plan all of which were last completed 4/12/2022. License agrees to update documents submit to CCLD. Technical Assistance issued.

Licensee, Londa Quinn's Administrator Certification 6026353735 is currently pending and LPA confirmed training and payments have been submitted to CCLD.

LPA requested the following documents be sent to CCL by COB 8/18/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Given.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2023 12:33 PM - It Cannot Be Edited

Created By: Dominic Tobola On 07/18/2023 at 12:11 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: Q & Q FAMILY CARE HOME	FACILITY NUMBER: 480111474
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 client centrally stored medication records. LPA found CSMR for clients (C1, C2 & C3) incompleted with no indications of start dates for prescribed medications which poses/posed a potential health & safety risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Licensee agrees to continue utilizing the Centrally Stored Medication Records form to record received prescription medicaitons, order numbers and start dates. LIC9098 Proof of Corrections form to be submitted to CCLD confirming the facility understands and agrees to the plan of correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kimberley Mota

LICENSING EVALUATOR NAME:

Dominic Tobola

LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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