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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609334
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:58:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20230424111908
FACILITY NAME:PEOPLE'S CARE GILLESPIEFACILITY NUMBER:
197609334
ADMINISTRATOR:LAKESHA BUCHANANFACILITY TYPE:
735
ADDRESS:4021 GILLESPIE RDTELEPHONE:
(661) 269-2676
CITY:ACTONSTATE: CAZIP CODE:
93510
CAPACITY:4CENSUS: 4DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Amparo Murvin, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Insufficient staffing to meet resident needs
INVESTIGATION FINDINGS:
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At 10:05am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above to conduct an initial complaint visit. LPA met with the Administrator and explained the reason for this visit.

At approximately 10:25 am, LPA conducted a physical plant walk through. From 10:40am-11:30pm, LPA conducted interviews and collected relevant documents.

At 10:05am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above to conduct an initial complaint visit. LPA met with the Administrator and explained the reason for this visit.
At approximately 10:25 am, LPA conducted a physical plant walk through. From 10:40am-11:30pm, LPA conducted interviews and collected relevant documents.

CONTINUED...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20230424111908
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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'S CARE GILLESPIE
FACILITY NUMBER: 197609334
VISIT DATE: 04/27/2023
NARRATIVE
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Allegation: Insufficient staffing to meet resident needs

It was alleged that the facility is not providing the 424 hours of basic staffing as indicated in the program design but is only providing 304 basic staffing hours not including the 92 hours of 1:1 staffing support for resident #1 (R1). Prior to the visit, LPA received information from a reliable source, that the facility does not have sufficient staffing according to their approved program design, and after interviewing the Administrator she admitted the facility did not have the 424 hours of basic staffing in addition to the 92 hours of 1:1 staffing, and they were in the process of hiring additional staff. The Administrator indicated she has two (2) new staff going through the on boarding process and is waiting for the staff to clear so that they will have a start date. LPA reviewed the staffing schedule and found that the facility has total of 338 basic staffing hours and not the program design hours of 424. LPA also reviewed the program design where it stated the facility would provide 424 hours of basic staffing hours. Based on document review the facility is not providing the 424 hours for sufficient staffing to meet the client’s needs, therefore, the allegation,” Insufficient staffing to meet resident needs,” is deemed SUBSTANTIATED.

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 9099D included with this report.



Appeal rights issued. Exit interview conducted. Report Delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20230424111908

FACILITY NAME:PEOPLE'S CARE GILLESPIEFACILITY NUMBER:
197609334
ADMINISTRATOR:LAKESHA BUCHANANFACILITY TYPE:
735
ADDRESS:4021 GILLESPIE RDTELEPHONE:
(661) 269-2676
CITY:ACTONSTATE: CAZIP CODE:
93510
CAPACITY:4CENSUS: 4DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Amparo Murvin, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not providing services as agreed in the facility cost statement and program design
INVESTIGATION FINDINGS:
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Allegation: Staff are not providing services as agreed in the facility cost statement and program design

It was alleged that the facility is not providing services as described in the Admission Agreement in that the facility is not following R1’s IPP by providing consisting 1:1 additional staffing (12 hours during the weekdays and 16 hours on the weekend). LPA reviewed R1’s IPP and verified that R1 was granted 12 hours of additional 1:1 staffing for the weekdays and 16 hours of additional 1:1 staffing for the weekends. LPA reviewed the staffing schedule and found that 92 hours of 1:1 additional staffing was being provided. The Administrator indicated the facility is providing 1:1 Staffing to R1, but the facility was including the 92hours with the total basic staffing hours. She indicated although they are not billing the 1:1 hours R1 is still being provided with a 1:1 staff. LPA reviewed the LIC 500 (Staffing Schedule) and the facilities personal staff schedule and found there to be 92hours of 1:1 staffing for R1 and a total of 338 basic staffing hours. Based on document review the facility is providing services as agreed in the program design and is providing R1 with the appropriate 1:1 additional staffing hours; therefore the allegation, “Staff are not providing services as agreed in the facility cost statement and program design,” is deemed UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230424111908
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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'S CARE GILLESPIE
FACILITY NUMBER: 197609334
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2023
Section Cited
CCR
80065(a)
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80065(a) Personnel Requirements (a)Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement was not met as evidence by:
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The Administrator isi in the preocess of interviewing candidates, and two (2) new staff are in the on boarding process. The Administrator will provide an updated LIC500 24hour staffing schedule including LVN hours.
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Based on file review the Licensee did not met the requirements for the section cited above in that the Licensee did not provide enough basic staffing hours as indicated in their program design to meet the needs of the clients, which poses a potential health and safety risk for clients 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4