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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602019
Report Date: 10/24/2023
Date Signed: 10/24/2023 10:38:21 AM

Document Has Been Signed on 10/24/2023 10:38 AM - 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PEOPLE'S CARE COVINA HILLSFACILITY NUMBER:
198602019
ADMINISTRATOR:RAMOS, JOLLIEREY (JOLLIE)FACILITY TYPE:
735
ADDRESS:1412 E COVINA HILLS RDTELEPHONE:
(626) 498-0075
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 4CENSUS: DATE:
10/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:-Registered Behavioral Therapist Daisy Sawyers / Direct Support Staff Irene Sandoval and LPTTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon made an unannounced subsequent visit to continue to address separate incidents that were observed / noted on visit date: 10/6/23. LPA met with Registered Behavioral Therapist Daisy Sawyer and Direct Support Staff Irene Sandoval. LPA discussed the purpose of todays visit.

The purpose of today's visit is to deliver deficiencies, noted on 809D. Deficiencies noted on 10/6/23 for:
  • Construction occurring at the above facility and facility failed to report construction to CCLD.
  • Death of a client that occurred on 9/10/23, was not reported to CCLD.

An exit interview has been conducted with RBT Daisy Sawyers and a copy of this report and Appeal Rights was provided. LPA Calderon will email reports to Administrator Jollie Ramos and District Manager Lee Strollo.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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 10/24/2023 10:38 AM - It Cannot Be Edited


Created By: Ashley Calderon On 10/24/2023 at 09:52 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEOPLE'S CARE COVINA HILLS
FACILITY NUMBER: 198602019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2023
Section Cited
CCR
80061(b)(1)(A)

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80061(b)(1)(A)Reporting Requirements
(b) Upon the occurance....any of the events specified... a report shall be made to the licensing...within the agency's next working day... In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (A)Death of any client from any cause.
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District Manager Lee Strollo will provide a training for applicable staff whom is responsible to report to CCLD. Training will be on Title 22 Reporting Requirements- 80061 and Licensee/ Admin/ District Manager will provide training sheet log in and material used to conduct training by POC due date of 11/24/23 to LPA Calderon's email.
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The requirement is not met as evidenced by:

Not reporting to CCLD- death of a client dated 9/10/23. LPA Calderon called caseload LPA Bonnie Tao and stated LPA was unaware of death and no unusual incident report / death reports were provided to CCLD. LPA unable to obtain documentarians during visit.
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Type B
11/24/2023
Section Cited
CCR80086(a)

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80086(a) - Alterations to Existing Building or New Facilities.

Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
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District Manager Lee Strollo will provide a training for applicable staff whom is responsible to report to CCLD. Training will be on Title 22: 80086- Alterations to Existing Building or New Facilities and Licensee/ Admin/ District Manager will provide training sheet log in and material used to conduct training by POC due date of 11/24/23 to LPA Calderon's email.
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The requirement is not met as evidenced by:

Not reporting to CCLD- construction start date 9/18/23, LPA during time of visit observed materials inside and outside of the facility and construction for flooring in all common areas. LPA notified caseload LPA Bonnie Tao whom was unaware of construction occurring at the facility and did not get notified by facility.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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