<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700203
Report Date: 05/17/2024
Date Signed: 05/17/2024 04:16:07 PM

Document Has Been Signed on 05/17/2024 04:16 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 KEYESPORT WAYFACILITY NUMBER:
342700203
ADMINISTRATOR/
DIRECTOR:		KIZZY THORNFACILITY TYPE:
735
ADDRESS:8317 KEYESPORT WAYTELEPHONE:
(916) 735-5620
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Kizzy Thorn, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on an incident report submitted to the Department recently. LPA met with Kizzy Thorn, Administrator, and stated the reason for the inspection. Also present was staff, Saron Welodon. (2) clients were present in the common area and (2) clients were in their rooms at the start of the inspection. LPA observed client (C1) to be working on an art project at the kitchen table during the inspection.

LPA and the Administrator discussed (C1) leaving the community on 5/7/24 (4:00 pm) and asking neighbors for a caffeinated drink. The Administrator immediately followed client and reminded him that AWOLing is not the way to get something he wants. The Administrator continued to give verbal prompts to (C1) and then offer him a PRN medication when (C1) became increasingly agitated when he was not receiving what he wanted. (C1) began to walk into oncoming traffic on a busy adjacent street, and the Administrator had to call local law enforcement due to (C1) not listening to any verbal prompts and for his safety and that of staff. The police arrived, (C1) told them he wanted to hurt himself, and so was taken for a 5150 at a nearby hospital. The incident report didn't indicate if/when (C1) had returned to the community.

(C1) returned from the hospital later on the same day. As a result of being out of the facility during the time evening medications were administered, (C1) missed several medications scheduled for 8:00 pm. (C1) had a follow up medical appointment and is in the process of changing his primary care physician to get a better response following these types of incidences. In addition, increased counseling sessions have been scheduled almost daily with several outside counselors. (C1) stated he feels the additional sessions are helping him. (C1) has also been placed on a waiting list to attend a day program as soon as possible.

It appears the facility followed its behavior plan once (C1) began to AWOL and show unsafe behaviors. There are no deficiencies cited in this report. Exit interview. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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 1