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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002831
Report Date: 05/19/2022
Date Signed: 05/19/2022 04:17:48 PM

Document Has Been Signed on 05/19/2022 04:17 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 KRANS COURTFACILITY NUMBER:
345002831
ADMINISTRATOR:ANDRES, JUANFACILITY TYPE:
735
ADDRESS:8530 KRANS COURTTELEPHONE:
(909) 287-3557
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 4DATE:
05/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Shadayleon Richardson, House LeadTIME COMPLETED:
04:38 PM
NARRATIVE
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On 5/19/2022 at 3:45PM Licensing Program Analyst (LPA) Williams arrived at the facility to conduct an unannounced case management visit. LPA met with House Lead Shadayleon Richardson. LPA called and spoke with Amanda, who is filling in as Administrator while Juan Andres is out. LPA explained the purpose of the visit. Prior to initiating the case management visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical. In addition, Staff screened LPA prior to entering the facility.

LPA was notified by phone call and received an incident report stating that on 5/08/2022 Client 1 (C1) was found in the bathroom washing their arms with Comet and stated she wanted to bleach her skin. Administrator Juan Andres stated the Comet had been left on the counter and the chemical cabinet had been left unlocked. Administrator immediately put the Comet away, monitored the residents skin, and called poison control. Administrator was told that the powder form was not as dangerous as the liquid form and to monitor the resident for any open wounds or change of color in skin. Staff then monitored C1 for any changes in condition.

As a result of today's inspection, a deficiency is cited pursuant to California Code of Regulations, Title 22, Section 87309(a) regarding cleaning solutions being left accessible to clients. Deficiencies are listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s gives House Lead permission to sign, as Administrator is currently away. Her signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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 05/19/2022 04:17 PM - It Cannot Be Edited


Created By: Jacob Williams On 05/19/2022 at 11:42 AM
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 KRANS COURT
FACILITY NUMBER: 345002831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
87309(a)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Licensee or Administrator shall submit in writing how they shall ensure the cleaning chemicals are locked up when there are no staff present.
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Based on observation, the licensee did not comply with the section cited above allowing cleaning chemicals to be left out on the bathroom counter leading to a client rubbing it on skin which poses an immediate health, safety or personal rights risk to persons 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:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022


LIC809 (FAS) - (06/04)
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