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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700173
Report Date: 06/02/2022
Date Signed: 06/02/2022 03:42:06 PM

Document Has Been Signed on 06/02/2022 03:42 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PEOPLE'S CARE WILLORAFACILITY NUMBER:
392700173
ADMINISTRATOR:SIMON, ARNEATHAFACILITY TYPE:
735
ADDRESS:949 WILLORA RDTELEPHONE:
(209) 957-3662
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 5CENSUS: DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Arneatha SimonTIME COMPLETED:
04:00 PM
NARRATIVE
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On 6/2/22 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a case management related to medication errors as a follow up to the visit of 4/12/22. LPA Jensen met with Arneatha Simon and explained the purpose of today's visit.

LPA Jensen reviewed records including but not limited to the following records for Resident 1(R1): February/March MAR, Pre-Placement Appraisal, LIC 603, Regional Center Behavioral Support Plan and Update and Physician's Report LIC 602. LPA Jensen also interviewed the Administrator a DSP.

LPA Jensen observed the medication storage unit and confirmed that medications are locked and inaccessible to clients in care. LPA Jensen also observed a shift change narcotic count with three staff members participating.

Based on the LPA Jensen's observations, record reviews and interviews it was determined that a required medication was not administered as prescribed on 4/7/22. It was also observed that the MAR for R1 was missing initials 3/7/22, 3/11/22 and 3/20/22.

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. An immediate civil penalty is assessed in the amount of $250 for a repeat violation having occurred within 12 months, see LIC421FC.

An exit interview was conducted and a copy of appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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 2
Document Has Been Signed on 06/02/2022 03:42 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/02/2022 at 02:58 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEOPLE'S CARE WILLORA
FACILITY NUMBER: 392700173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2022
Section Cited
CCR
80075(b)

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Health Related Services
...
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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The Licensee agrees to have MARs and medications audtited daily and will submit a monthly attestion that the audit occured and the findings once a month on the first of the month but no later than the 3rd of the month beginning 7/1/22 and the documentation will be submitted to Community Care Licensing (CCL) by email to maja.jensen@dss.ca.gov.
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Based on interviews conducted, records reviewed and LPA observations, medication was not administered to R1 on April 7, 2022 and the MAR for R1 was missing entries for 3 dates in March of 2022. This poses 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:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
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