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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002831
Report Date: 04/08/2022
Date Signed: 04/08/2022 12:59:49 PM

Document Has Been Signed on 04/08/2022 12:59 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:
04/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Juan AndresTIME COMPLETED:
01:10 PM
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On 04/08/2022 at 12:20 PM Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced to conduct a case management investigation. LPA met with Administrator Juan Andres and explained the purpose of the visit. Prior to initiating the complaint investigation 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 mask.

The reason for the visit is a phone call was received on 04/06/2022, concerning an incident that occurred on 04/04/2022 in which it was reported that a staff had headbutted a resident while in care.

LPA reviewed the following documents: Client's Physician's Report. Review of resident's Physicians Report revealed they are on the autism spectrum and is non verbal.

LPA interviewed staff working at time of visit: S2 and S3. Interviews can be found on the attached LIC812.

Administrator to submit SIR to LPA by close of business (4/8).

At this point, there are no deficiencies cited during today's visit. LPA will consult with LPM regarding possible exclusion. An exit interview was conducted, and a copy of the report was emailed to administrator Juan Andres.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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