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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606909
Report Date: 12/03/2019
Date Signed: 12/03/2019 11:12:13 AM

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:ANDREA DEVERSFACILITY TYPE:
735
ADDRESS:22005 PARTHENIA AVENUETELEPHONE:
(818) 715-0977
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:5CENSUS: 4DATE:
12/03/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brenda Watts-BellTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in conjunction with Community Services Specialist (CSS) Cristina Perez. LPA and CSS were greeted by staff upon arrival and explained the purpose of today's visit, Regional Manager Brenda Watts-Bell arrived shortly after.

LPA and CSS conducted this visit in order to follow up on a medication error that was observed by CSS on 11/7/19. During that visit, CSS observed that 2 medications, belonging to Residents 1 and 2 (R1 and R2), were not present in the facility.

During today's visit LPA and CSS reviewed all client medications, observing two of Resident 3's (R3's) medications to not be present in the facility. Regional Manager stated that R3's medication is brought to the day program by staff. Regional Manager was unable to identify one of the names on R3's Medication Assistance Record (MAR) and could not confirm where R3's afternoon medications were during today's visit. Staff 1 stated that the afternoon medications are put in R3's backpack for them to bring to day program.

At 10:50am LPA spoke with Administrator Brandy Maynard who stated that R3's afternoon medications are either brought to the day program every day by facility staff or put in R3's backpack for them to bring to day program. Administrator stated either facility staff or day program staff will pass the medication for R3 each day, and identified the unknown MAR initial as being for "Day Program." R3's physician report and preplacement appraisal indicate that they are unable to store their own medications.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 809D page.
SUPERVISOR'S NAME: Jill NakataTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
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
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: 12/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2019
Section Cited

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80075(k) The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by:

Based on observations and interviews, the facility failed to ensure that R3's centrally stored medications were secured and inaccessible which poses an immediate risk to residents in care.
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Type B
12/03/2019
Section Cited

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80075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.


This requirement is not met as evidenced by:
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Based on the observations of a credible witness, on 11/17/19 the facility failed to ensure that two of R1 and R2's prescribed medications were kept in the facility which poses a potential risk to residents in care.
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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: Jill NakataTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2019
LIC809 (FAS) - (06/04)
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