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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700203
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:34:38 PM

Document Has Been Signed on 07/12/2023 04:34 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:AMANDA BRITTFACILITY TYPE:
735
ADDRESS:8317 KEYESPORT WAYTELEPHONE:
(909) 342-7163
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 4DATE:
07/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Crystal Paules, Lead DSPTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection regarding an incident occurring on 7/10/23. LPA met with Crystal Paules, Lead DSP, Jeanna Gold, DSP, Kannyse "Kay" Winn, DSP and Alayzah Martin,DSP in training. Administrator was attending an appointment at another facility and was not able to meet LPA. LPA was informed (3) clients (C1-C3) were resting in their room and observed (1) client (C4) return to the home, at 3:50 pm.

LPA discussed situation occurring on 7/10/23, at approximately 5:30 pm, when client (C1) took drinks from a parked convertible car in the court and then took a large rock and damaged staff (S1's) car. The incident report received on 7/11/23 notes that S1 tried to redirect C1 per client's Behavioral Support Plan; however, C1 became more angered and caused additional damage to S1's vehicle. LPA was shown a photo of the damaged windshield and front end of S1's car during today's inspection.

Lead DSP stated that neighbors provided assistance to S1 when C1 became physically aggressive towards S1. S1 called the local police department who arrived on scene and took a report of the situation that had escalated.

The incident report notes that S1 monitored C1 for safety during the entire incident but C1 was able to pick up a rock and throw it, causing damage. S1 also appropriately avoided any physical altercation by maintaining a safe distance from C1. The incident report states that staff will continue to supervise C1 and other clients safety while in the community/neighborhood.

LPA reviewed the most recent Behavior Support Plan, updated in June 2023. LPA to follow up with the Administrator and Regional Center regarding any follow up medical appointments scheduled for C1.

There are no deficiencies cited in this report.

Exit interview with Lead DSP. Copy of report provided to Lead DSP.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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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