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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700203
Report Date: 04/23/2024
Date Signed: 04/23/2024 12:51:53 PM

Document Has Been Signed on 04/23/2024 12:51 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:
04/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Kizzy Thorn, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analysts (LPA's) Sabrina Calzada and Kevin Mknelly arrived unannounced to conduct a case management inspection to follow up on an incident report submitted to the Department recently. LPA's met with Kizzy Thorn, Administrator, and stated the reason for the inspection. Also present were staff, Crystal Paulus and DreYonna Baisden. Clients (C1 and C2) were in the common areas and (C3) was in his room at the start of the inspection. Client(C4) was out of the community during the inspection.

During today's inspection, LPA's discussed the incident that occurred on 4/17/24 (approx 3:00pm) between (C1) and (S1). LPA's also reviewed training documentation for all staff, including (S1), and interviewed the Administrator.

The incident that occurred on 4/17/24 appeared to be the result of (S1) failing to follow (C1's) behavior plan which led (C1) to escalate to property abuse of (S1's) vehicle. (S1) intervened during an intervention (S2) was involved in with (C1) and verbally abused and physically pushed (C1) away from (S1's) vehicle. Minimal damage occurred to (S1's) vehicle and (C1) was unharmed. (S2) successfully redirected (C1) to return to the home and (C1) de-escalated with no further incident.

(S1) was sent home immediately following the incident on 4/17/24 and placed on Administrative Leave the following day while an internal investigation was conducted. The Licensee's investigation resulted in (S1's) employment being terminated due to failing to follow facility protocol.

Following the review of documentation and interview, the Department found that (S1) violated (C1's) personal rights by failing to treat them with dignity and respect.

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

Exit interview with the Administrator and Regional Director (by phone). Copy of report and appeal rights provided to the Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
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 04/23/2024 12:51 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 04/23/2024 at 12:10 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 KEYESPORT WAY
FACILITY NUMBER: 342700203

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2024
Section Cited
CCR
80072(a)(1)

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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Licensee/Administrator will submit a written policy that any team member should alert the Administrator when there is a concern for another staff's emotional readiness for work.

Documentation of the policy and the associated training is due by 5/7/24 by email/FAX.
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Based on interview and documentation reviewed, the Licensee's employee (S1) failed to follow facility policy with (C1's) behavioral plan, which resulted in a potential 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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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