197610332-6-3-2025-31-AS-ERIS-DHB2KL-20250603172807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610332
Report Date: 06/03/2025
Date Signed: 06/03/2025 05:28:19 PM

Document Has Been Signed on 06/03/2025 05:28 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PEOPLE'S CARE LANCASTER C12		FACILITY NUMBER:	197610332
ADMINISTRATOR/ DIRECTOR:	PICKENS, YOLANDA		FACILITY TYPE:	738
ADDRESS:	8543 W AVENUE C12		TELEPHONE:	(909) 287-3557
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 4		CENSUS: 2	DATE:	06/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Yolanda Pickens - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 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	On 06/03/2025 at 3:05 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection using the Inspection Tool. LPA rang the door bell and nobody answered. LPA contacted the Administrator, Yolanda Pickens by telephone and informed her LPA was at the facility and explained the reason for the visit. Staff opened the gate for LPA and granted access. LPA met with administrator shortly after. One (01) client and three (03) staff were in the facility. At approximately, 03:25 p.m. LPA Rios toured the physical plant of the facility, and the following was observed. Upon entry LPA observed a desk with a binder for visitor check-ins, hand sanitizer, gloves, and mask for clients, staff and visitors. The home was observed clean and clear of clutter. Kitchen: Appliances and fixtures were observed to be functional. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food, properly stored. Common Areas: These includes two (02) living areas, two (02) dining area, a garage used as recreation room, and art room.The furniture was observed in good repair. The dining table and chairs set the capacity of the facility. Hallways and passageways are free of obstruction. LPA observed five (05) fire extinguishers through out the facility fully charged with service date 02/10/2025. At 5:24 p.m., LPA observed the administrator test a dual smoke and carbon monoxide detector. Detectors are hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly. Fire doors leading to the bedrooms automatically closed. (Continue to LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE'S CARE LANCASTER C12	FACILITY NUMBER: 197610332
	VISIT DATE: 06/03/2025

NARRATIVE

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(Continued from LIC809)
Bedrooms: Personal accommodations in client bedrooms were observed for safety, privacy, and comfort. LPA toured four (04) of four (04) client bedrooms. Bedrooms are private. Client bedrooms were inspected and observed with all required furnishings.

Bathrooms: LPA toured three (03) bathrooms, accessible to clients. Bathroom were clean and properly supplied with toilet paper, hand towels, and hand soap. LPA observed functional bathroom fixtures.

Surrounding Grounds: Entry/exits and hallways were free of obstruction. The backyard is accessible to clients and has appropriate outdoor furniture. The outdoor area was free of hazards. There are no bodies of water. The facility is entirely fenced in with permitted delayed egress. Delayed egress was inspected by LPA at 3:33 p.m., and observed functioning properly.

LPA was informed by administrator, client #1(C1) was issued and eviction notice dated 05/02/2025. Notice was provided to responsible party and other agencies. However Community Care Licensing Division did not receive a copy. A copy was immediately emailed to LPA. C1 is still in the facility and according to the administrator ELARC is working with the facility to find placement.

Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff files, resident records, or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection.

Deficiency Cited and cleared on todays visit (refer to LIC809-D). Exit interview conducted. Appeal Rights Provided. Copy of report signed and provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/03/2025 05:28 PM - It Cannot Be Edited

Created By: Evelin Rios On 06/03/2025 at 04:46 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE'S CARE LANCASTER C12	FACILITY NUMBER: 197610332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80068.5

(e) The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in not providing the Department with a copy of a 30-day written notice within five days of giving it to the client #1 (C1) which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2025
	Plan of Correction
1 2 3 4	Eviction notice copy provided. POC cleared on todays visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Eva Miller
NAME OF LICENSING PROGRAM MANAGER:

	Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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