<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426555
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:39:00 PM

Document Has Been Signed on 04/06/2022 04:39 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
, 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: 3DATE:
04/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Blanca GonzalezTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst's (LPA's) Stephanie Williams and Rayshaun Nickolas made an unannounced visit to the facility in order to conduct a case management visit. LPA's Williams and Nickolas identified themselves to Caregiver, Blanca Gonzalez, who was also informed of the purpose of the visit. LPA Williams spoke with the Administrator, Rachel Riley, over the phone.

On 1/12/22, a Department Investigator interviewed Staff #1 (S1) regarding allegations made on Complaint Control #18-AS-20210921132836. According to the Investigation Report, S1 indicated that on at least occasion, they threatened to "punch" Resident #1 (R1).

Deficiencies are being cited for violations of resident's Personal Rights. An exit interview was conducted where this report was discussed and a copy was provided to Gonzalez at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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 04/06/2022 04:39 PM - It Cannot Be Edited


Created By: Stephanie Williams On 04/06/2022 at 02:05 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
, CA 92507

FACILITY NAME: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
87468.1(a)(3)

1
2
3
4
5
6
7
87468.1- Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, ... This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
The Licensee shall conduct training on Regulation 87468.1 for all staff and send proof to the Department by POC date.
8
9
10
11
12
13
14
Based on interviews, the Licensee did not ensure the personal rights of R1. This is an immediate personal rights risk to resident's in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Efren Malagon
LICENSING EVALUATOR NAME:Stephanie Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2