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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606909
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:57:37 PM


Document Has Been Signed on 05/04/2022 04:57 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIAFACILITY NUMBER:
197606909
ADMINISTRATOR:TANGA NUNNERYFACILITY TYPE:
735
ADDRESS:22005 PARTHENIA AVENUETELEPHONE:
(818) 715-0977
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:5CENSUS: 3DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mariam TendoTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit due to follow up to a incident report that was submitted on 4/4/22. LPA conducted a previous visit on 4/12/22 to address the incident. LPA met with the administrator and explained the reason for this visit.

On 4/4/22 an incident report was submitted regarding client #1 (C1) who was being changed and assisted to bed by staff # 1(S1). While S1 was assisting C1 another staff (S2) stood by and observed. S2 observed S1 attempt to pull up C1's left pant leg that C1 attempted to turn around when S1 used their forearm to stop S1 from turning and then S1 lifted their arm and made contact with C1's left outer thigh with an open hand. Shortly after that C1 tried to grab S1, and S1 kept C1 at a distance with their forearm and with an open hand made contact with C1's upper arm. S2 immediately told S1 that their action was inappropriate and then checked C1 to see if they had any marks, signs of pain or distress to which C1 had none. S2 stated that the contacts made with the open hand was not aggressive or meant to hurt C1. The administrator was called and notified about the incident. S1 was immediately placed on leave from their job duties. Facility reported the incident to North Los Angeles Regional Center and Community Care Licensing. Since then all staff have had Pro-Act Training which is learning to redirect and handle behaviors, to ensure that staff and clients are protected at all times.
Deficiency cited on LIC 809 D. Appeal rights explained. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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Document Has Been Signed on 05/04/2022 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2022
Section Cited

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Personal Rights- each client shall have personal rights which include:To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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Based on interviews conducted C1 was hit on their left upper thigh by S1 which posed an immediate health and safety risk to C1.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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