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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700203
Report Date: 11/09/2022
Date Signed: 11/09/2022 04:45:28 PM

Document Has Been Signed on 11/09/2022 04:45 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PEOPLE'S CARE KEYESPORT WAYFACILITY NUMBER:
342700203
ADMINISTRATOR:AMANDA BRITTFACILITY TYPE:
735
ADDRESS:8317 KEYESPORT WAYTELEPHONE:
(909) 342-7163
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 4DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Stacey Takara, DSP and Elisha Peeler, DSP TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada completed a case management inspection while at the facility to conduct a required annual inspection . LPA met with Stacey Takara, DSP and ,DSP Elisha Peeler. who contacted Administrator, Amanda Britt, by phone. Administrator stated she was unable to attend the inspection since she was at a related facility. LPA completed required Department COVID-19 testing protocols, applied hand sanitizer before entering the facility and wore a surgical mask. Additionally, LPA was screened by staff upon entering the facility. LPA observed (4) clients at the start of the inspection.

The Department received an incident report on 11/8/22 for an incident involving client (C1) on 11/7/22. LPA interviewed staff (S1) who was present during the incident. S1 stated around 9:00 pm, client became upset and entered into behaviors when he was not able to have more sugar, specifically a soda. C1 began walking back and forth, visibly upset. S1 went to tell another staff (S2) that C1 was entering a behavior, and when S1 and S2 went to check on C1, C1 had walked away from the facility. Incident report states that C1 was out of sight for 10 minutes. Staff tried to convince C1 to return to the facility but he didn't want to. Staff then called non-emergency who responded at 10:00 pm approximately. C1 finally agreed to return to the facility after receiving some food from a fast food restaurant. C1 was given a PRN medication also upon returning to the facility and then went to his room. Staff attempted to verbally redirect C1 before he AWOL'd and followed C1 to ensure his safety and attempted to redirect him back to his home, per his behavior plan. C1 does not require 1:1 supervision. Documentation reviewed in C1's file shows that C1 is not conserved but cannot leave the facility unattended. Documentation also shows that C1 has a history of elopements, and Administrator stated that it has become worse over the last two months.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809-D page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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 11/09/2022 04:45 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 11/09/2022 at 04:16 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PEOPLE'S CARE KEYESPORT WAY
FACILITY NUMBER: 342700203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
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 is not met as evidenced by:
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Licensee/Administrator agree to conduct in-service staff training to discuss the AWOL and how it could have been prevented. Also, Administrator agrees to continue discussing C1's exit seeking behaviors with medical professionals and the regional center service coordinator to try and find a solution.
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Based on documentation review and interviews conducted, the Licensee did not ensure that the appropriate supervision was provided to client (C1) on 11/7/22 at approximately 9:00 pm when C1 was able to leave the facility unattended, which resulted in an immediate health and safety risk to clients in care.
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Documentation of in-service training to be provided to the Department by 11/23/22 by fax or email.

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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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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