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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426555
Report Date: 05/27/2021
Date Signed: 05/27/2021 07:08:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200916151032
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: 6DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Caregiver Blanca Gonzalez TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility perimeter gates are chained shut.
Residents was not provided appropriate sleeping arrangements while in care
Facility staff speak inappropriately to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived at the facility to investigate as well as to deliver findings for the allegation(s). LPA was greeted and granted entry by Caregiver Blanca Gonzalez. LPA George explained the purpose of the visit and discussed the elements of the allegations with the Administrator Rachel whom came to the facility and left 30 minutes after meeting with LPA. The investigation consisted of interviews, LPA's observations and review of pertinent documents.

Allegation #1 Facility perimeter gates are chained shut.
Upon LPA George's arrival, LPA observed the facility gates to be chained shut, as well as during the virtual visit conducted on 9/21/20, While interviewing Administrator Rachel, the reason for the chain is because the electric gates have been broken since August of 2020, and the chain and lock was added as a precaution due to the frequency of the traffic on the street. Therefore the allegation of Facility perimeter gates are chained shut is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20200916151032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2021
Section Cited
HSC
80022(a)(i)
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80022 Plan of Operation
(a) Each licensee shall have and maintain on file a current, written, definitive plan of operation.
Prior to the use of secured perimeters, applicants or licensees of Group Homes and Adult Residential Facilities seeking to utilize secured perimeters pursuant to Health and Safety Code section 1531.15 shall submit the Department of Developmental Service's written approval and the approved component of the applicant's or licensee's plan of operation to the Department as specified in the California Code of Regulations, Title 17, Chapter 3, Sub chapter 4, Article 12, Sections 56072(c). This requirement is not met as evidenced by: Based on observation the licensee did not obtain prior approval for a secured perimeter on 1 out of 1 times. This poses a potential health, safety, and personal rights risk to person's in care.
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The licensee shall submit a request for a secured perimeter as well as have the fence fixed, and submit proof to the department by 5pm on the due date indicated.
Type B
06/10/2021
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
Based on observation, record review and interview the licensee did not ensure that 2 out of 6 residents had comfortable accommodations.
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The licensee will bring provide residents in room # 5 with bed frames and submit proof to the department by 5pm on the due date indicated.
Type B
06/10/2021
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:
Based on observation, and interviews the licensee did not ensure that the resident's were spoken to appropriately on at least 2 occasions. This poses a potential health, safety or personal rights risk to persons in care.
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The licensee will conduct an in-service on personal rights. Proof will be submitted by 5pm on the due date indicated.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200916151032

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: 6DATE:
05/27/2021
UNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Caregiver Blanca Gonzalez TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
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3
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9
Residents were not provided bed linens
Facility staff are not ensuring that residents are properly dressed
Facility staff are not assisting residents with transfers out of bed
INVESTIGATION FINDINGS:
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2
3
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5
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7
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13
Licensing Program Analyst (LPA) Javina George arrived at the facility to investigate as well as to deliver findings for the allegation(s). LPA was greeted and granted entry by Caregiver Blanca Gonzalez. LPA George explained the purpose of the visit and discussed the elements of the allegations with the Administrator Rachel whom came to the facility and left 30 minutes after meeting with LPA. The investigation consisted of interviews, LPA's observations and review of pertinent documents.

Allegation # 1 Residents were not provided bed linens.
LPA George conducted a tour of the interior and exterior of the facility. LPA observed in each resident bedroom to have the proper bed linens (sheets, comforter and pillow with a pillowcase). Additionally observed extra linens in the linen cabinet located in the hallway. Therefore the allegation of Residents were not provided bed linens, is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200916151032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2021
NARRATIVE
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Allegation #2 Facility staff are not ensuring that residents are properly dressed

LPA George observed all residents to be groomed and dressed appropriately that were walking/moving around the facility. LPA George observed staff encouraging resident's to handle their daily hygiene by taking a shower and changing their clothes. Based on observation, LPA was unable to corroborate the allegation of Facility staff are not ensuring that residents are properly dressed, the allegation is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.


Allegation # 3 Facility staff are not assisting residents with transfers out of bed

LPA George observed that 2 of the resident's to be in bed and the others walking around the facility. LPA George was able to interview bedridden resident whom stated that staff does assist them with getting out of the bed when needed. All other Resident's are non-ambulatrory, and stated that if help was needed, that staff would assist. Therefore the allegation of Facility staff are not assisting residents with transfers out of bed is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report and 9099C was provided to Caregiver Blanca Gonzalez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20200916151032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/27/2021
NARRATIVE
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Allegation #2 Residents was not provided appropriate sleeping arrangements while in care.

LPA George conducted a tour of the facility. LPA observed the beds in bedroom #5 to be on the floor and not on an actual bed frame. There is not documented reason to prove that both resident's residing in the room requiring for the beds to be as they are. Based on observation that allegation of Residents was not provided appropriate sleeping arrangements while in care is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation #3 Facility staff speak inappropriately to resident.
LPA George conducted interviews and based on information provided, staff are speaking to resident's inappropriately as they are yelling at resident's instead of using an appropriate voice tone when speaking to them. The allegation of Facility staff speak inappropriately to resident is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on observation, records review and interviews deficiencies will be cited per Title 22, Division 6, of the California Code of Regulations.


An exit interview was conducted, and a copy of this report, 9099C, 9099D and appeal rights was provided to Caregiver Blanca Gonzalez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5