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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006074
Report Date: 10/12/2023
Date Signed: 10/12/2023 11:28:41 AM


Document Has Been Signed on 10/12/2023 11:28 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SUCCESSFUL PEOPLE LLC #5FACILITY NUMBER:
306006074
ADMINISTRATOR:SNODDY, FRANCESFACILITY TYPE:
735
ADDRESS:1774 W CHALET AVETELEPHONE:
(310) 902-4893
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:4CENSUS: 4DATE:
10/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Kenya HuffTIME COMPLETED:
11:40 AM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on self-reported incident reports received in the Orange County Regional Office (OCRO) on 09/22/23 and 09/29/23 regarding Client #1 (C1). LPA met with Staff #1 (S1) Kenya Huff and discussed the purpose of the inspection. Administrator (AD) Frances Snoddy appeared via telephone.
The incident reports state the following: On 09/21/23, C1 left the facility, staff followed and attempted to redirect C1 but lost sight of C1, and the Anaheim Police Department was notified. On 09/28/23, C1 returned to the facility with minor injuries.
During today’s inspection, LPA conducted health and safety checks on C1 and the other clients and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food, the electricity and water were running, the facility had soap and paper towels, and the medications and sharps were property stored. LPA confirmed placement and functionality of door alarms. LPA interviewed S1, C1, and requested and reviewed copies of the resident roster, staff roster, and C1’s Client File.
The investigation into the incident revealed the following. C1 left the facility, was missing, sustained minor injuries, and was found and returned. However, C1’s Physician’s Report dated 05/09/23 does not indicate C1 is able to leave the facility unassisted. In addition, C1’s Individual Program Plan dated 03/24/22 indicates that “when [C1] becomes upset, [C1] impulsively makes high risk decisions that have frequently placed [C1] at crisis facilities and the ER. It is important to intervene when [C1] has eloped and attempted to de-escalate.” Review of C1’s Physician’s Report dated 05/09/23 reveal that multiple portions have not been completed, including ambulatory status and whether C1 can leave the facility unassisted.
Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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 10/12/2023 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated they will retrain staff on the elopement protocol and submit proof to LPA by POC due date
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Based on interview and documents, the licensee did not provide adequate supervision to C1 when C1 eloped, was missing, and sustained minor injuries while not being able to leave the facility unassisted, which posed an immediate safety risk to persons in care.
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Type B
11/09/2023
Section Cited
CCR80069(c)(2)

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80069 Client Medical Assessment … (c) The medical assessment shall include the following: (2) Identification of the client's special problems and needs. This requirement was not met as evidenced by:
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Licensee stated they will schedule a doctor’s appointment, have a new Physician’s Report completed with all sections filled in, and submit the new Physician’s Report to LPA by POC due date.
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Based on documents, the licensee did not ensure C1’s Physician’s Report indicated C1’s ambulatory status and whether C1 could leave the facility unassisted, which poses a potential safety risk to persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2