198602019-10-9-2023-28-AS-FFIS-CWL5NZ-20231013200710

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602019
Report Date: 10/06/2023
Date Signed: 10/09/2023 02:07:46 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2021 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210422092344

FACILITY NAME:	PEOPLE'S CARE COVINA HILLS		FACILITY NUMBER:	198602019
ADMINISTRATOR:	RAMOS, JOLLIEREY (JOLLIE)		FACILITY TYPE:	735
ADDRESS:	1412 E COVINA HILLS RD		TELEPHONE:	(626) 498-0075
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	4	CENSUS: 3	DATE:	10/06/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Registered Behavioral Therapist Daisy Sawyer and Direct Support Staff Irene Sandoval		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility is operating out of ratio

INVESTIGATION FINDINGS:

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On 10/06/23, Licensing Program Analyst (LPA) Ashley Calderon conducted a subsequent unannounced complaint visit regarding the allegation listed above. This licensing report supersedes licensing report dated 10/14/22.

During today’s visit, LPA Calderon met with Registered Behavioral Therapist Daisy Sawyer and Direct Support Staff Irene Sandoval and informed staff the purpose of the visit was to redelivered complaint investigation findings and the findings will remain the same.

Per LPA Calderon 06/15/23 correspondence with Administrator Jollie Ramos, revealed that all clients were present at the facility in February and March 2021, and three (3) out four (4) clients attending day program. On 6/20/23, Administrator Ramos confirmed with LPA Calderon via email, that clients were attending day program virtually in February and March 2021, due to the COVID-19 circumstances. (Continuation 9099-C...)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210422092344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 198602019
	VISIT DATE: 10/06/2023

NARRATIVE

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LPA noted one (1) staff present for four (4) clients in care for the following dates:
• March 03, 2021 - 10:30PM – 6:30AM - one (1) Direct Support Professional (DSP) present.
• March 05, 2021, - 2PM -10PM - one (1) Licensed Psych Tech (LPT) staff present.
• March 06, 2021, - 2PM-10PM - one (1) Licensed Psych Tech (LPT) staff present.
• March 06, 2021, - 9PM - 6AM - one (1) Direct Support Professional (DSP) staff present.
• March 06, 2021, - 9PM - 6AM - one (1) Direct Support Professional (DSP) staff present.
• March 07, 2021, - No nocturnal shift staff reported on punch report.
• March 11,2021 - 10PM - 6:20AM - one (1) Licensed Psych Tech (LPT) staff present.
• March 12, 2021 - 10PM - 6AM - one (1) Licensed Psych Tech (LPT) staff present.
• March 13, 2021- 2PM -10:10PM - One (1) Direct Support Professional (DSP) present.
• March 14, 2021 – 2PM - 10PM - One (1) Direct Support Professional (DSP) present.
• March 14, 2021 - 10:20PM - 6:20AM One (1) Direct Support Professional (DSP) present.
• March 18, 2021, 10pm - 6am one (1) one (1) Licensed Psych Tech (LPT).
• March 19, 2021, 6AM – 2PM - One (1) Direct Support Professional (DSP) present.
• March 20, 2021, 6AM - 2:10pm -One (1) staff present.
• March 20, 2021, 2pm- 10pm, - One (1) staff present.
• March 21, 2021, 10PM - 1:20AM, - One (1) staff present.
• March 21, 2021, No staff from 1:20AM - 6AM, no staff marked in Employee Punch Report provided.
• March 23, 2021, - 10PM - 6:10am, - One (1) staff present.
• March 30, 2021, - 10PM - 6:10AM, - One (1) staff present.
• March 31, 2021, - 6AM - 2PM, -One (1) staff present.
• March 31, 2021, 10PM-6:20AM, One (1) staff present.

Based on the facilities Program Design it states " People's Care Covina Hills will provide at least 396 hours of direct support per week when there is a census of 4 residents in the home. The staffing schedule will include a minimum, two awake staff and on duty, staff 24 hours per day, 7 days a week. The use of secured perimeters shall not substitute for adequate staff in sufficient numbers to meet the care and supervision needs of all residents, including additional staffing as determined to be necessary by a resident's Regional planning team. On-call staff will be available Monday -Friday during work program hours, in the event that a resident does not attend day program. There will be no less than two direct support staff at all times when residents are under supervision of facility staff and approved staffing schedules will be followed.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210422092344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 198602019
	VISIT DATE: 10/06/2023

NARRATIVE

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Interview conducted on 8/19/22 with San Gabriel / Pomona Regional Center with Quality Assurance for the above home, informed LPA Calderon and LPM Fernando Fierros that client placed at the above home would be rare to have a 1:1 ratio, it would be inappropriate placement home.

The facility failed to have adequate staffing, they shall of a minimum of 2 staff on duty at all times when clients in care are under staff supervision and facility failed to meet the hours specified in their Plan of Operations / Program Design.

Based on LPAs Calderon findings, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099-D.

An exit interview was held, reports were provided to RBT- Daisy Sawyer and appeal rights were given.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210422092344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 198602019
	VISIT DATE: 10/06/2023

NARRATIVE

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On 5/26/23, LPA Calderon interviewed Administrator Ramos telephonically, Administrator explained that when all four (4) clients are in care at the facility, the Facility Staff Schedule for Direct Support Staff is marked “O” and the Lead Staff which is marked “X”. LPA Calderon confirmed with Administrators that LPT’s are the Lead Staff and the staff schedule is marked with an “X”.

LPA's Calderon and Tao during investigations process interviewed staff Staff #1 (S1) - Staff #7 (S7) and Clients #1- Clients #4 (C1-C4)

LPA Calderon reviewed the Facility Staff Schedule which indicates “NO DAY PROGRAM” on the top of the schedule.

Review of the staff schedule indicates the following:
Weekday Schedule:
• Monday through Friday, 12AM – 6PM - one (1) Lead Staff and one (1) Direct Care Staff to be present.
• Monday through Friday, 3PM – 10PM - one (1) Lead Staff and two (2) Direct Care Staff to be present.
• Monday through Friday, 10PM – 12AM - one (1) Lead Staff and one (1) Direct Care Staff to be present.

Weekend Schedule:
• Saturday through Sunday, 12AM to 9AM, one (1) Lead Staff and one (1) Direct Care Staff present.
• Saturday through Sunday, 9AM- 10PM, one (1) Lead Staff and two (2) Direct Care Staff to be present.
• Saturday through Sunday,10PM – 12AM - one (1) Lead Staff and one (1) Direct Care Staff to be present.

LPA Calderon reviewed Employee Punch Reporting hours for the month of March 2021 and based on the review of staff timesheets:

Continuation 9099-C...

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210422092344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 198602019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/31/2023 Section Cited CCR 85065(b)	1 2 3 4 5 6 7	85065(b) Personnel Requirement: The licensee shall employ staff as necessary to ensure provision of care and supervision to meet clients needs. The requirement is not met as evidenced by:	1 2 3 4 5 6 7	LPA Calderon spoke to Krystal Baker (LPT) and Baker will ensure to inform Administrator Jollie Ramos that he will review and submit the latest:
	8 9 10 11 12 13 14	LPA Calderon review Plan of Operations / Program Design, facility staff schedule and March 2021 timesheets. Insufficient staff scheduled based on time sheets, facility had (4) clients present during Feb/ March of 2021 and time sheets show only 1 staff scheduled for certain hours, see 9099 / 9099-C...	8 9 10 11 12 13 14	LIC 500 Staff Roster including Hours worked for Admin. and Staff, Plan of Operations (Program Design/ Staff Hours) and (2) Facility Staff Schedule to Licesening, In addition, Administrator will review Title 22 Personnel Requirements / Administration Responsibilities, provide documenation of a self in-service review including hours and material reviewed and Admin. signature. Moreover, Submit a Plan to ensure sufficient staff covering to meet clients needs. Admin will clear POC by due date: 10/31/23 for the above mention and to show documenation to show staff increase in event staff shortage / absent , staff back up plan if applicable info regarding Agency used and submit LIC308 Designation of Responsibility for AM,PM and NOC shift. LPA Calderon will in addition email Admin. at jramos@peoplecare.org.
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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.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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