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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426555
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:28:01 PM

Document Has Been Signed on 09/18/2024 04:28 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:APPEARANCE QUALITY HOMEFACILITY NUMBER:
366426555
ADMINISTRATOR/
DIRECTOR:
RILEY, RACHELFACILITY TYPE:
740
ADDRESS:10752 OAKWOOD AVE.TELEPHONE:
(760) 956-2800
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 5DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Blanca GonzalezTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with staff, Blanca Gonzalez, and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (6), and a current census of (5). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. The backyard activity area shaded and surrounded by a self latching gate. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and bedroom lighting. Resident bathrooms were maintained clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured at 111 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms, laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation plan and emergency telephone numbers. Sharps were kept locked; however, LPA observed cleaning solutions (comet abrasive powder) in resident's unlocked bathroom cabinet and in an unlocked kitchen cabinet. Deficiency cited.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly

Care & Supervision: The facility has 24 hours a day, 7 days a week staff coverage.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: APPEARANCE QUALITY HOME
FACILITY NUMBER: 366426555
VISIT DATE: 09/18/2024
NARRATIVE
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Health Related Services: Resident medications were centrally store in a locked cabinet. LPA observed that resident #1 (R1) medication log was not up-to-date. Staff did not log R1's pm medications on several days. LPA also observed that resident #2 (R2) was not given their medication as prescribed. R1's prescribed medication from 9/7 was still in the medication packet and staff logged medication as given on that day.

Record Review: Resident files reviewed had admissions agreements, physician’s reports, preplacement appraisals, needs and services plans. Staff files reviewed had First Aid/CPR certifications, criminal record clearances, training, and health screenings. The facility’s liability insurance and emergency drill training are up to date.

Based on LPA observations and records reviewed, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report and corrections plans were discussed. Copies of the reports were provided with appeal rights to staff Gonzalez at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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Document Has Been Signed on 09/18/2024 04:28 PM - It Cannot Be Edited


Created By: Magda Malcore On 09/18/2024 at 03:39 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: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining cleaning solutions inaccessible to residents in care; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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The staff removed the cleaning solutions and placed them in a locked cabinet. No futher action is required.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by R1's prescribed medication from 9/7 was still in the medication packet and staff logged medication as given on that day; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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The Licensee/Administrator shall provide medication administration training to staff and submit proof of training to licensing by POC due 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2024 04:28 PM - It Cannot Be Edited


Created By: Magda Malcore On 09/18/2024 at 04:10 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: 09/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(a)
Resident records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by PA observed that resident #1 (R1) medication log was not up-to-date. Staff did not log when resident's pm medication were given on several days; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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The Licensee Licensee/Administrator shall provide medication administration training to staff and submit proof of training to licensing by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024


LIC809 (FAS) - (06/04)
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