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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800106
Report Date: 01/22/2024
Date Signed: 01/22/2024 03:58:27 PM

Document Has Been Signed on 01/22/2024 03:58 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:QUALITY CARE HOMEFACILITY NUMBER:
565800106
ADMINISTRATOR:MARIA CASTILLO 98FACILITY TYPE:
735
ADDRESS:4859 EAST MUIRWOOD COURTTELEPHONE:
(805) 579-9605
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 3CENSUS: 1DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria CastilloTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 1:30 p.m. The last annual conducted at this facility was on 1/24/2023. When the LPA arrived, there was one (1) staff and one (1) client present. The LPA was greeted at the door by Administrator, Maria Castillo, and at this time the reason for the visit was explained. Entrance interview conducted.

At 1:35 p.m., the LPA along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 1:38 p.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. The knives and sharps are stored in a locked cabinet inside the food pantry inaccessible to clients in care. The water temperature was measured in the kitchen sink at 107.9 degrees Fahrenheit at 1:44 p.m.

Common areas: Living and dining room furniture were observed to be in good condition. At 1:59 p.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was last charged and serviced on 1/11/2024.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: QUALITY CARE HOME
FACILITY NUMBER: 565800106
VISIT DATE: 01/22/2024
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(Report Continued from LIC 809...)

Garage/Outdoor: The washer and dryer are in the garage. Cleaning supplies and disinfectants are stored in a locked cabinet inaccessible to clients. The LPA observed an adequate supply of emergency food and water. The backyard has a covered outdoor area equipped with furniture for client use. The side gate was latched. No bodies of water noted at the time of visit.

Restrooms: There is one client restroom which was observed clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathroom was sufficiently stocked with soap and paper towels. The hot water temperature was measured at 105.9 degrees Fahrenheit at 1:54 p.m.

Bedrooms: There two (2) client rooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed. There was a linen closet in the hallway with a sufficient supply of linens and towels.

Records: The LPA reviewed facility files at 2:08 p.m. The LPA reviewed one (1) client file for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. At 2:16 p.m., records review revealed that Client #1 (C1) does not have a negative Tuberculosis (TB) test on file. The Administrator made an appointment for C1 to have TB test done at the time of the visit.

The LPA reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid/cpr certification, and yearly training. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home. The last disaster drill was conducted on 12/19/2023.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
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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: QUALITY CARE HOME
FACILITY NUMBER: 565800106
VISIT DATE: 01/22/2024
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(Report Continued from LIC 809C...)

Medications: Medications review began at approximately 2:55 p.m.; medications are centrally stored in a locked box in the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

The LPA interviewed one (1) staff at 3:30 p.m.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2024 03:58 PM - It Cannot Be Edited


Created By: Martha Arroyo On 01/22/2024 at 03:36 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUALITY CARE HOME
FACILITY NUMBER: 565800106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above as the facility does not have a negative TB test on file for C1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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The Administrator made an appoitment for C1 to be tested for TB. The Administrator has agreed to submit proof of a negative TB test for C1 to CCL no later than 1/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


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