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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602544
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:10:35 PM

Document Has Been Signed on 09/08/2023 12:10 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PEOPLE'S CARE FERREROFACILITY NUMBER:
198602544
ADMINISTRATOR:ANGELA WILLIAMSFACILITY TYPE:
735
ADDRESS:431 FERRERO LNTELEPHONE:
(323) 330-7545
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 3DATE:
09/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:George Aliimatafitatafi - House ManagerTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced case management visit to the facility. Upon arrival, LPA met with George Aliimatafitatafi - House Manager and explained the purpose of the visit.

During the course of the investigation related to Complaint Control Number: 28-AS-20220705163858 which was investigated by Investigator Miles with the Investigations Branch, the following was determined:

On 07/01/22 during a Crisis Prevention Intervention (CPI), Resident #1 (R1) warned staff, “I’m going to swallow screws so I can go to the hospital”. On 07/03/22 during the NOC-shift, Staff Member #1 (S1) witnessed another Staff Member #2 (S2) who was supposed to provide direct care and supervision to R1 throughout the night, was caught sleeping multiple times during their shift. On 07/04/22, R1 ingested screws at his mother’s house which R1 stated were obtained from the facility. He was transported to the hospital for evaluation and “17 screws that were 2 ½ inches long” were found in his stomach. Staff Member #3 (S3) admitted R1 took the screws from his dresser while under the care and supervision of the facility. Staff members interviewed also indicated that R1 needed a higher level of care and supervision. Investigator Miles also determined that the facility failed to seek timely medical attention for R1. Although R1 complained about pain to his hand on 07/01/22 after CPI, R1 was not sent to the hospital for evaluation until 07/04/22 were the hospital discovered a “spiral fracture of the right 1st metacarpal bone.”

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on an 809D. Exit interview held and a copy of the report along with appeal rights were provide to Administrator Angela Williams.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/08/2023 12:10 PM - It Cannot Be Edited


Created By: Tena Herrera On 09/07/2023 at 10:48 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 FERRERO
FACILITY NUMBER: 198602544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/09/2023
Section Cited
CCR
80078(a)

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(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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Administrator to submit written plan to explain how this regulation will be met moving forward.
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This requirement is not met as evidenced by: Investigator Miles determined that R1 ingested screws he obtained from the facility. Additionally S2 was observed sleeping during their shift. This poses an immediate health, safety, and/or personal rights risk to the clients in care.
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Request Denied
Type A
09/09/2023
Section Cited
CCR80075(a)

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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Administrator to submit written plan to explain how this regulation will be met moving forward.
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This requirement is not met as evidenced by: Investigator Miles determined that facility failed to obtain timely medical care for R1 after suffering a injury. This poses an immediate health, safety, and/or personal rights 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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
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