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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426555
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:57:29 PM

Document Has Been Signed on 05/27/2021 03:57 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, 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: 6DATE:
05/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Caregiver Blanca Gonzalez TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to conduct a health and safety check. 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.

LPA conducted a tour of the facility on observed in the kitchen to have a lock on the refrigerator as well as the pantry to be locked. Administrator Rachel stated that the locks are there because Resident #1 R1 will eat all of the food. LPA reviewed the facility file and there is not an approved waiver or exception to have a locked refrigerator and or pantry. A deficiency will be cited.

At 12:13pm LPA observed an unidentified female in the backyard on the side of the facility with a blue shirt, pants and socks on. LPA Greeted the unidentified female whom confirmed that she was not a resident at the facility. Administrator Rachel stated that the female is a friend of the family and is granted entry to shower and stay for a bit due to being homeless. The individual is not associated to the facility. A deficiency will be cited.

LPA George observed the bedridden resident to be in room #2, and not in room number as indicated per the facility sketch and fire clearance

LPA observed the facility is having renovations done as they are adding bedrooms, however did not notify the department, a deficiency will be cited.
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.

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Document Has Been Signed on 05/27/2021 03:57 PM - It Cannot Be Edited


Created By: Javina George On 05/27/2021 at 01:48 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
, 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
CCR
80072(a)(3)

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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:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by: The licensee having the pantry and refrigerator locked.
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The licensee will request a waiver to have the refrigerator and pantry locked and submit proof to the department by 5pm on the due date indicated.
Type B
06/10/2021
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance
80019 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or.. This requirement is not met as evidenced by the licensee allowing for a family friend to utilize the amenities at the facility. This poses a potential health, safety or personal rights risk to person's in care.
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The licensee will either have the individual associated or do not allow them to come to the facility. Proof will be submitted to the department by 5pm on the due date indicated.
Type B
06/10/2021
Section Cited
CCR80022(a)(7)

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80022 Plan of Operation
(a) Each licensee shall have and maintain on file a current, written, definitive plan of operation.
(7) A sketch of the building(s) to be occupied, including a floor plan which describes the capacity's of the buildings for the uses intended, room dimensions, and a designation of the rooms to be used for non ambulatory clients, if any. This requirement is not met as evidenced by:
Based on observation the licensee did not follow the plan of operation on 1 out of 1 times
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The licensee will move the bedridden resident from room # 2 and into rooom # 3 as indicated per the facility sketch and fire clerance. Licensee will submit proof to the department by 5pm on the due date indicated.
Type B
06/10/2021
Section Cited
CCR
80034(a)(4)

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80034 Submission of a new application
(a) A licensee shall file a new application as required by Section 80018 whenever there is a change in conditions or limitations described on the current license, or other changes including but not limited to the following:
(4) Any increase in capacity.
This requirement is not met as evidenced by:
Based on observation, interview and record review the licensee did not submit a new application for an increase in capacity. This poses a potential health, safety or personal rights risk to person's in care.
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The licensee will submit a new application for an increase in capacity to the department by 5pm on the due date indicated.
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 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


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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, 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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Additionally LPA George was informed that there may a resident whom is receiving food stamps and has to buy groceries for the facility. LPA George interviewed Administrator Rachel whom did not deny the allegation and could not produce any receipts for the groceries purchased.

Rachel stated that it would be on the bank statement and that most shopping was done at Costco. LPA George reviewed 4 statements and was not able to confirm that to be true. However Rachel did confirm that there is one resident #2 (R2) that does have an EBT card. LPA observed for R2 to have some food kept inside their room, but the rest was with the food inside of the refrigerator. A deficiency will be cited.

Based on the observations made during today’s visit, deficiencies were observed and 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 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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2021 03:57 PM - It Cannot Be Edited


Created By: Javina George On 05/27/2021 at 02:25 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
, 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
CCR
80026(a)(f)

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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(a) A licensee shall not be required to accept for admission or continue to care for any client whose incapacitates, as documented by the initial or subsequent needs appraisals, would require the licensee to handle such client's cash resources.
(f) The licensee or employee of a licensee shall not make expenditures from clients' cash resources for any basic services in these regulations, or for any basic services identified in a contract/admission agreement between the client and the licensee. This requirement is not met as evidenced by:
Based on observation, interview and record review the licensee did not ensure that the resident used their own resources for basic services. This poses a potential health, safety or personal rights risk to person's in care.
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The licensee will submit proof of grcoery receipts for the month of April and May 2021 to the department by 5 pm 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.
SUPERVISOR'S 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


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