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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700073
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:20:58 PM

Document Has Been Signed on 10/25/2024 04:20 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEOPLE'S CARE WINFINFACILITY NUMBER:
342700073
ADMINISTRATOR/
DIRECTOR:		TAUKOSHIUA DOVE-MOSLEYFACILITY TYPE:
735
ADDRESS:3418 WINFIN WAYTELEPHONE:
(916) 480-9660
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 3DATE:
10/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:John O'Brien, District ManagerTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with District Manager, John O'Brien, to issue a citation in relation to a separate inspection conducted on today's date, 10/25/2024. The following information was obtain from a separate inspection concluded on 10/25/2024:

Interview with Alta California Regional Center (ACRC) Service Coordinator (SC) indicated that they notified the vendors regarding resident (R1's) death, including R1’s day program and the transportation company that provided services to R1. SC stated that R1’s day program reported to them that, on 11/16/2022, the morning in which R1 passed away, they contacted the facility regarding R1’s absence from the day program and was told that R1 was absent due to a behavior at the care home. R1’s day program also reported that the transportation driver showed up at the facility to pick up R1 on 11/16/2022 and overheard staff say “don’t let them know.” Interview with transportation company confirmed they were not informed of R1’s death when arriving to the facility on 11/16/2022 and heard staff say, “don’t tell [them] nothing.” The Department received a recording of a phone call made from the facility to R1’s day program dated 11/18/2022 indicating that R1 “will not be coming in today due to [R1] not feeling well.” Phone call was made from staff member (S5). Representative from R1’s day program stated that they were informed of R1’s death by SC on 11/17/2022 and no one (at the time of interview) from the facility reported R1’s death to R1’s day program. Interview with staff member (S1) indicated that they were going to inform R1’s transportation aide of R1’s death, but they were told by Administrator, Stephanie Henry, not to tell aide. Interview with staff member (S3) indicated that District Manager, Kourtney Hamilton, and Administrator were the ones who stopped S1 from informing R1’s transportation aide of R1’s death.

** Report continued on 809-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
VISIT DATE: 10/25/2024
NARRATIVE
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The Department received care notes documented by staff for R1. S1 wrote in an entry dated 11/18/2022 that R1 woke up, took their medications, and got dressed for day program. R1 ate breakfast and sat in a chair listening to music while waiting for the transportation van. S1 walked R1 out to the van and brought R1’s lunch and a bag of extra clothes in case of an accident. R1 was still at program when S1 ended her shift. R1's day program records indicated that R1 was not present on 11/18/2022 due to "medical." The Department also received a Special Incident Report (SIR) for R1 dated 11/15/2022 indicating that, on 11/17/2022, R1 was refusing to get up off the floor.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited for false claims per regulation 80012 on the attached 809-D page.

Exit interview was conducted with District Manager. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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Document Has Been Signed on 10/25/2024 04:20 PM - It Cannot Be Edited


Created By: Michael Hood On 10/25/2024 at 02:23 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
80012(a)

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80012 False Claims (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
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Facility will conduct an in-service training for all staff regarding false claims. Facility will submit date and materials of training to LPA by POC due date.
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Based on interviews conducted and records reviewed, the facility did not ensure statements and documentation were true in reflecting R1's death on 11/16/2022, including documents sent to the Department, which poses a potential health, safety, and personal reights risk to the residents 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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