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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601281
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:46:51 PM

Document Has Been Signed on 09/10/2024 03:46 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:QCARE RESIDENTIAL FACILITY IIFACILITY NUMBER:
075601281
ADMINISTRATOR/
DIRECTOR:		CUNANAN, JOAQUINFACILITY TYPE:
740
ADDRESS:4363 FAIRWOOD DRIVETELEPHONE:
(925) 676-8727
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Joaquin Cunana, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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On 09/10/2024 at 10:45 am, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an 1 year annual. LPA met with Caregiver, Ryan Mondez and explained the purpose of the visit. Administrator, Joaquin Cunanan and Floresblanca Cunanan arrived at approximately 11:20 am. The facility’s fire clearance was approved for 5 non-ambulatory and 1 Bedridden.

LPA toured facility with including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are occupied by the residents. All outdoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA 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 119 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. Sharps were locked and inaccessible to residents.

LPA reviewed 6 residents files, and two staff files.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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 6
Document Has Been Signed on 09/10/2024 03:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/10/2024 at 03:07 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QCARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 075601281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having medication left inside residents’ rooms unlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Administrator agree to remove and lock up all medication. Administrator will submit photo to CCLD by CLD date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2024 03:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/10/2024 at 03:07 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QCARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 075601281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to resident shared bathroom drawer is broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator agree to fix the broken drawer in the residents share bathroom. Administrator will send photo to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above conducted staff files reviewed training is incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator agree to provide a plan on staff training, and provide proof of completion to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/10/2024 03:46 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/10/2024 at 03:07 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: QCARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 075601281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above residents central medication list/PRN medication do not have a label on the medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator agree to get all the PRN medication lable and match with central medication order. Adminstrator will submit photo of each PRN with a label to CCLD by POC date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: QCARE RESIDENTIAL FACILITY II
FACILITY NUMBER: 075601281
VISIT DATE: 09/10/2024
NARRATIVE
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The following deficiencies were observed during the visit:

-At 11:10 am, LPA observed Medication are left inside residents’ rooms unlock
-At 11:30 am, LPA observed Chemical underneath resident restroom and underneath kitchen sink
-At 11:56 am, LPA observed the exit way inside the resident’s room are block
-At 12:20pm, LPA observed resident shared bathroom drawer is broken
-At 2pm, LPA conducted staff files reviewed training is incomplete

-AT 2:30pm, LPA reviewed residents’ central medication list/PRN medication do not have a label on the medication

-The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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