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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006074
Report Date: 08/30/2024
Date Signed: 08/30/2024 04:38:01 PM

Document Has Been Signed on 08/30/2024 04:38 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUCCESSFUL PEOPLE LLC #5FACILITY NUMBER:
306006074
ADMINISTRATOR/
DIRECTOR:		SNODDY, FRANCESFACILITY TYPE:
735
ADDRESS:1774 W CHALET AVETELEPHONE:
(310) 902-4893
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Staff #1TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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LIcensing Program Analyst, (LPA) Rose Ruppert conducted an unannounced visit to follow-up on an incident report received in our office on August 26, 2024. LPA was greeted and granted entry by Staff #1. This is a level 5 facility.

The purpose of our visit is to follow-up on a case management incident where a client eloped from the facility on the evening of August 23, 2024. Upon interviewing Staff #2 and Staff #3, the elopement occurred with one staff member present for the overnight shift. Staff #2 and Staff #3 had ended their shift at 8pm, they are the 12-8pm shift, and there was one staff member at the facility. Client left the facility and Staff #2 and Staff #3 returned to work to assist in locating client. The night staff member contacted Anaheim Police and an officer responded. Client walked to a family member's home twenty miles away.

Staff shifts are 8am-4pm with two direct support professionals (DSP) during this shift. Two additional DSPs come from 12-8pm. The overnight shift has one DSP from 8pm-8am.

LPA requested client's file for Individual Program Plan (IPP) which was created on October 25 2023. LPA interviewed client who wanted to be taken to the Crisis Assessment Team (CAT). Staff #3 contacted facility house lead who directed them to contact the CAT team. The CAT team arrived at 2:30pm and client was transferred to Anaheim Global Medical Center for assessment.

Based on LPA observation, interviews and file review an immediate civil assessment of $500 is being assessed for lack of supervision for clients in care. Licensee will send an updated care plan to address the client's elopement behavior.

An exit interview was conducted via phone with Adriana Harbin, Facility House Lead and a copy of this report was given to the facility, along with the LIC 809-D, LIC 421IM and appeal rights. Staff #1 was asked to sign report for facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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 08/30/2024 04:38 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 08/30/2024 at 03:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SUCCESSFUL PEOPLE LLC #5
FACILITY NUMBER: 306006074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a)...the following shall apply:(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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The Licensee (LE) will provide documentation to LPA on updated IPP and services plan to ensure the health and safety of clients in care by Friday, September 6, 2024 via email.
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Based on Licensing Program Analyst (LPA) observation and interview, the licensee did not ensure the client in care had adequate supervision which poses an immediate health and safety risk to 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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


LIC809 (FAS) - (06/04)
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