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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601282
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:47:21 PM

Document Has Been Signed on 11/02/2022 01:47 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 IIIFACILITY NUMBER:
075601282
ADMINISTRATOR:CUNANAN, JOAQUINFACILITY TYPE:
740
ADDRESS:4369 FAIRWOOD DRIVETELEPHONE:
(925) 682-0111
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joaquin Cunanan, AdministratorTIME COMPLETED:
01:55 PM
NARRATIVE
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On 11/2/2022 at 1:15PM Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Joaquin Cunanan, Administrator.

While LPA L. Hall was conducting a complaint investigation (15-AS-20210520122215) on 11/2/2022. During interview S1 stated that he did not report an incident and death report for R1 to CCLD.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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 2
Document Has Been Signed on 11/02/2022 01:47 PM - It Cannot Be Edited


Created By: Laura Hall On 11/02/2022 at 01:20 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 III
FACILITY NUMBER: 075601282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence...
This requirement was not met as evidence by:
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Administrator agreed to submit a self-certification that the regulation 87211 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.
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Based on LPA's interview and record review the Licensee did not comply with the section cited above in reporting incidents, which poses a potential health and safety risk to clients in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022


LIC809 (FAS) - (06/04)
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