075601282-9-22-2023-15-AS-PWAN-CVWT47-20230922142329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601282
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:23:35 PM

Document Has Been Signed on 09/22/2023 02:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	QCARE RESIDENTIAL FACILITY III		FACILITY NUMBER:	075601282
ADMINISTRATOR:	CUNANAN, JOAQUIN		FACILITY TYPE:	740
ADDRESS:	4369 FAIRWOOD DRIVE		TELEPHONE:	(925) 682-0111
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 3	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Analyn Bravante, Caregiver		TIME COMPLETED:	02:40 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 09/22/2023 at 12:02 PM, Licensing Program Analysts (LPAs) P. Watson and A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPAs were greeted by caregiver and explained the purpose of the visit. Administrator was unable to join the visit and allowed caregiver Analyn Bravante to sign report. The facility’s fire clearance was approved for 5 Non Ambulatory and 1 Bedridden . LPAs toured facility with caregivers including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 117 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/18/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/10/2023. Report continues on 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QCARE RESIDENTIAL FACILITY III	FACILITY NUMBER: 075601282
	VISIT DATE: 09/22/2023

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
26
27
28
29
30
31
32

At 12:05 PM, LPA reviewed 3 of 3 residents records. At 12:20 PM, LPA reviewed 4 of 6 staff records and 4 of 4 have first aid training and associated to the facility. At 1:00 PM, LPA reviewed a sample of 3 of 3 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/13/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiency was observed during inspection:
-At 1:02 PM LPAs were informed that caregivers perform glucose testing for R1.

The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted and a copy of this report provided along with Appeal rights

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 09/22/2023 02:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QCARE RESIDENTIAL FACILITY III	FACILITY NUMBER: 075601282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87628(a)

87628(a) Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by staff (S1) performing glucose testing for resident (R1) which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs were informed that S1 performs testing for R1, R1 is not on hospice or receiving care from home health
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator will review regulation and submit a plan to address R1 diabetic care needs and submit a copy to CCL by POC date.

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3