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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426555
Report Date: 07/15/2021
Date Signed: 07/15/2021 11:47:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:APPEARANCE QUALITY HOMEFACILITY NUMBER:
366426555
ADMINISTRATOR:RILEY, RACHELFACILITY TYPE:
740
ADDRESS:10752 OAKWOOD AVE.TELEPHONE:
(760) 956-2800
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 7DATE:
07/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Rachel Riley-AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Javina George conducted an unannounced health and safety check. LPA met with Administrator Rachel. Upon arrival LPA observed that the gate is still broken, the facility is using a lock that is typically used to secure a bike (rubber/plastic with a combination). Per previous discussion with Administrator the gate was to be fixed by 6/30/21. Administrator called the repair man during LPA's visit whom stated that he ordered the part and the fence should be fixed next week. LPA toured the physical plant and observed the facility to still be under construction. Administrator submitted the plans for construction to LPA during the visit, that were requested May 27, 2021 during LPA's last visit. The projected completion date is August 2021.

LPA observed that there is still a lock on the refrigerator as well as the pantry. The facility has more than the minimum requirement of a 2 day supply of non perishable food items and a 7 day supply of perishable food items.

LPA observed and greeted all resident's except one due to them being asleep during LPA's visit. The resident's were groomed, and appropriately dressed. At 10:57am LPA observed the facility to be over capacity. There to be an extra individual Resident # 7 (R7) asleep inside of bedroom number two, whom was identified as a resident and was placed by the County, per Administrator Rachel. Note that R7 is associated to the facility. LPA discussed the need to have someone relocated, as it is an immediate health and safety risk to the resident's in care, as the facility's fire clearance only granted approval for 6 non ambulatory resident's. Per Administrator there is supposed to be another resident #4 (R4) moving out by the end of this week. The move out date was confirmed to be tomorrow 7/16/21 afternoon.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555
VISIT DATE: 07/15/2021
NARRATIVE
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Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report, and appeal rights were provided to Administrator Rachel Riley.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2021
Section Cited

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87204 Limitation-Capacity and Ambulatory status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met by: Based on observation, interview, and record review the licensee did not stay within capacity on 1 of 1 times.

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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3