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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804109
Report Date: 08/09/2023
Date Signed: 08/10/2023 08:32:03 AM

Document Has Been Signed on 08/10/2023 08:32 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ALL QUALITY HOME CARE SERVICES, LLCFACILITY NUMBER:
486804109
ADMINISTRATOR:CARO, MARVINFACILITY TYPE:
735
ADDRESS:170 TERI CTTELEPHONE:
(510) 230-9897
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 0DATE:
08/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Marvin Caro, AdministratorTIME COMPLETED:
03:55 PM
NARRATIVE
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During the course of a complaint investigation on 7/31/2023, licensing program analyst(LPA), Leibert determined that C1 had been residing in the facility for two or three weeks and the administrator could not produce complete records for C1, which is required by Title Twenty-Two reg. 80070. Additionally, C1 is over the age of 59 years, which is the age limit for clients in facilities licensed as Adult Residential Facility.
LPA A. Canela arrived today unannounced, to conduct a Case Management visit and issue citation warranted from the 7/31/2023 visit and met with Administrator, Marvin Caro and went over several regulations.

In addition, LPA Canela went over regulation for 80019 Criminal Record Clearance and explained to Administrator, All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: obtain a fingerprint clearance, in addition to to other records.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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Document Has Been Signed on 08/10/2023 08:32 AM - It Cannot Be Edited


Created By: Araceli Canela On 08/09/2023 at 12:49 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: ALL QUALITY HOME CARE SERVICES, LLC
FACILITY NUMBER: 486804109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
80070(a)

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80070(a) Client records. The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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Clients moved out and Administrator agrees to provide care only within the scope of his license and will submit a signed and dated declaration attesting to the agreement.
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***Based on statements & file review, this requirement has not been met as evidenced by: C1 has resided in facility for two to three weeks & a current, complete record for C1 has not been maintained. This poses a potential risk to health and safety of C1.
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 Declaration to be submitted to CCL by POC date 8/18/2023 in order to clear the deficiency.
POC to LPA A Canela

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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