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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700203
Report Date: 01/31/2023
Date Signed: 01/31/2023 04:32:02 PM

Document Has Been Signed on 01/31/2023 04:32 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:
01/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Stacey Takara, Lisa Langley, and Lavina Thomas, DSP's.TIME COMPLETED:
04:35 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 regarding an incident occurring on 1/7/23. LPA met with Stacey Takara, Lisa Langley, and Lavina Thomas, DSP's. Lisa Langley 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 protocols and wore a surgical mask. Additionally, LPA was screened by staff upon entering the facility. LPA observed (2) clients at the start of the inspection and was advised (2) residents were attending a day program.

LPA discussed an incident report submitted to the Department with Administrator, Amanda, by phone. The incident occurred on 1/7/23 and involved client (C1). The Administrator stated she conducted an internal investigation and obtained written statements from staff who were directly involved or witnessed the incident. Administrator stated that C1 was never locked inside the facility van, the child lock was not on, and C1 is able to let himself out of the van but chose not to because he was holding sodas and a bag of food.

LPA discussed the incident with staff (S1), who witnessed the incident. S1 stated she observed the entire incident from the kitchen window and is certain staff (S2) did not lock C1 in the van as she did not notice any lights flashing or hear a beeping sound when the van is locked. S1 asserted that C1 didn't want to put his food/drink down to open the door, and staff are trained to let clients let themselves out of the van, to encourage independence. S1 stated C1 was in the van by himself for a minute until client (C2) went to open the van door for him, and staff do not ever use the child lock feature since clients are adults.

LPA reviewed a written statement submitted to the facility Administrator by staff (S2). S2 states after she parked the van, she exited and walked inside. There is no mention if S2 offered or agreed to assist C1 with opening the door since he was carrying food and drinks. S1 also stated she is not aware if there was any conversation about whether C1 asked for assistance with opening the door and if S2 ignored the request.

A Technical Advisory Note is being issued. Exit interview with Administrator by phone and copy of report left at facility. Administrator gave authorization for DSP Langley to sign report.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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 1