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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603557
Report Date: 10/22/2024
Date Signed: 10/22/2024 05:05:34 PM

Document Has Been Signed on 10/22/2024 05:05 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 NOGALFACILITY NUMBER:
198603557
ADMINISTRATOR/
DIRECTOR:		JASMIN SMITHFACILITY TYPE:
737
ADDRESS:8716 NOGAL AVENUETELEPHONE:
(909) 287-3557
CITY:WHITTIERSTATE: CAZIP CODE:
90606
CAPACITY: 4CENSUS: 3DATE:
10/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:19 PM
MET WITH:Jasmin Smith, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:13 PM
NARRATIVE
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LPA made unannounced visit to investigate allegations of abuse. LPA rang the door bell on the wrought iron door on the perimeter of the facility and as LPA was allowed entry and opened the door to enter, LPA was stuck on the head by the magnet locking mechanism that is attached to the upper right hand corner. LPA asked C1 if C1 has ever been hit by the mechanism and C1 stated yes. Staff S3 also stated S3 has been hurt by the mechanism twice.

Deficiency cited on 809D

Copy of report and appeal rights provided to administrator Jasmin Smith
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 05:05 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/22/2024 at 04:30 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 NOGAL
FACILITY NUMBER: 198603557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
80087(c)

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80087(c) Buildings and Grounds. Outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Licensee will repair, modify or replace the door by POC date and send proof to LPA by POC date.
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Facility has gate in the perimeter of the home that has mechanism that has stuck C1, S3 and LPA in the head which posed/poses a health and safety hazard for staff and 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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