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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602019
Report Date: 10/06/2023
Date Signed: 10/06/2023 04:28:29 PM

Document Has Been Signed on 10/06/2023 04:28 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
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: 3DATE:
10/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:-Registered Behavioral Therapist Daisy Sawyer, Direct Support Staff Irene Sandoval and LPT/ House Lead -Krystal Morlas-Baker TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon made an unannounced visit to address a separate incident at the time of the visit. LPA upon arrival was greeted by a contractor from Proficient Builders. LPA Calderon called Administrator Jollie Ramos and was not able to contact Admin. At 11:15am, Staff #1 (S1) and Staff #2 (S2) arrived at the facility and assisted LPA with visit. During visit, LPA discovered there was a death of a client that occurred on September 2023 and observed construction was in process inside the home.

During today's visit LPA collected resident an staff roster. LPA interviewed staff #1- staff #4 (S1-S4), Client #2 (C2), interviewed: Guest #1 (G1), Contractor, Property Manager and Project Manager from Proficient Builders. LPA attempt to interview facility assigned Quality Assurance and Service Coordinator from San Gabriel/ Pomona Regional Center via telephone call. LPA emailed San Gabriel/ Pomona Regional Center Quality Assurance and Service Coordinator to notify construction at the above facility, contact was not successful. LPA called caseload LPA Bonnie Tao and LPM Fernando Fierros to discuss the above issues.
Construction and death report was not reported to Licensing, LPA Tao verified no letter / email / Death Report or Special Incident Report (SIR) was provided to LPA Tao.

  • At 10:45am LPA arrived at the facility and no staff or clients were present. LPA noted construction tools in the backyard and materials. LPA interviewed contractor, whom stated construction start date was on 9/18/23 and approx. end date 10/18/23. LPA interviewed S1, S2 and S3 who were unaware if Administrator Jollie Ramos reported construction. S1, S2 and S3 informed LPA, they do not handle reporting requirements. LPA unable to communicate with Administrator. LPA Calderon and LPA Tap unaware of construction occurring at the above facility. No documentation's were available during time of visit.

Continuation 809-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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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
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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  • At around 1:15 pm, LPA Calderon was informed of a death of a client. LPA interviewed S1, S2 and S3 who were unaware if Administrator Jollie Ramos reported death. S1, S2 and S3 informed LPA they do not handle incident reports. Interview Staff #1 (S1) informed LPA that Client 1 (C1) was no longer residing at the facility due to death that occurred on 9/10/23. S1 and S3 informed LPA C1 died at the Hospital. LPA attempt to collect Death Report/ SIR, stated they do not have access to these documentation's, and it is the duty of Administrator Jollie Ramos that is responsible for the above stated. LPA unable to communicate with Administrator.


The following deficiency was cited on this date: see LIC 809-D. Due to time constraint LPA will return at another time.

An exit interview has been conducted with (LPT/ House Lead) Krystal Morlas-Baker and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR 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
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/06/2023 04:28 PM - It Cannot Be Edited


Created By: Ashley Calderon On 10/06/2023 at 04:13 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
, 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
10/09/2023
Section Cited
CCR
80086(a)

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80086(a)Reporting Requirements
(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
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(LPA Calderon will return at a further date)
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The requirement is not met as evidenced by:

No reporting to Licensing- construction start date 9/18/23.


(LPA Calderon will return at a further date)
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Type B
08/01/2023
Section Cited
CCR80061(b)(1)(A)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. 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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(LPA Calderon will return at a further date)
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The requirement is not met as evidenced by:

No reporting to Licensing- Death of Client dated 9/10/23.


(LPA Calderon will return at a further date)
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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: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023


LIC809 (FAS) - (06/04)
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