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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602544
Report Date: 09/21/2022
Date Signed: 09/21/2022 02:18:12 PM

Document Has Been Signed on 09/21/2022 02:18 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 FERREROFACILITY NUMBER:
198602544
ADMINISTRATOR:AARON EATONFACILITY TYPE:
735
ADDRESS:431 FERRERO LNTELEPHONE:
(909) 287-3557
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 3DATE:
09/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Aaron Eaton-Administrator TIME COMPLETED:
02:00 PM
NARRATIVE
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LPA Christine Wong conducted a CASE MANAGEMENT visit to this facility in conjunction with complaint control number 28-AS-20220815111123-The purpose of this Case Management visit is to issue a citation for a deficiency observed during the course of the complaint investigation.

While LPA interviewed the staff and clients and the facility staff would use physical restraint /CPI on clients, LPA requested the documentation for the containment, but LPA was only able to obtain the documentation for debriefing for July and August, 2022. The current administrator reported he started the position on June 26, 2022, and there's no documentation about debriefing for the prior month with the prior administrator. According to the facility plan of operation, the containment is necessary the details of the containment will be documented at least one of the two direct support staff involved in the containment.

The following deficiency is cited per Title 22, Division 6, CA Code of Regulations

Exit interview conducted with appeal rights covered.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 09/21/2022 02:18 PM - It Cannot Be Edited


Created By: Christine Wong On 09/21/2022 at 01:54 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 FERRERO
FACILITY NUMBER: 198602544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited
CCR
80022(k)

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80022 Plan of Operation
(k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

The requirement is not met as evidenced by:
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The administrator will ensure the staff follow the plan of operation for the facility Emergecny Intervention Plan and administrator will have a in service training with the staff about the Faciltiy Emergency Intervention Plan and send the staff training log to LPA by POC due date.
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Record reviewed and LPA's observation, LPA was not able to obtain any debriefing documents on June 2022, which posed a potential risk to the 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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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