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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700173
Report Date: 08/02/2022
Date Signed: 08/02/2022 03:08:42 PM

Document Has Been Signed on 08/02/2022 03:08 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: 5DATE:
08/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arneatha SimonTIME COMPLETED:
03:15 PM
NARRATIVE
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On 8/2/22 at approximately 1:00pm Licensing Program Analysts (LPA) Maja Jensen and Ruth Wallace arrived at facility unannounced to conduct a case management visit. LPAs Jensen and Wallace met with Administrator Arneatha Simon and explained the purpose of today's visit.

The facility self reported a repeat medication error as having occurred with resident 1 (R1). LPAs Jensen and Wallace interviewed Administrator Simon who confirmed that medication errors in the form of missed medication doses have occurred with staff 1 (S1). The Administrator also confirmed that personnel action was pursued and S1 is no longer at the facility.

LPAs Jensen and Wallace reviewed the Medication Administration Records (MARs) for R1 and verified the medication errors did occur over the course of the past year. LPAs also discussed the medication training protocols with the Administrator. The Limited Liability Corporation (LLC) has 3 Licensed Vocational Nurses (LVNs) on staff for this facility, direct care staff and Administrator for oversight of medication passes. Initial medication training and follow up in-service training is conducted with all employees as needed for the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiency is being cited on the attached 809D during this visit.

An exit interview was conducted and a copy of this report, appeal rights and a copy of the confidential names list were given to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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 08/02/2022 03:08 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/02/2022 at 02:40 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: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited
CCR
80065(f)(4)

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80065 Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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Licensee agrees to submit a Plan of Correction showing that a registered nurse will be employed by LLC to act as a consultant for the purpose of reviewing the quality and frequency of medication training and MARs every other month. The POC will be submitted to maja.jensen@dss.ca.gov by POC date of 8/30/22.
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(4) Assistance with prescribed medications which are self-administered.
This requirement was not as evidenced by:
Based on LPAs review of R1's MARs, staff training documentation and interview with Administrator, multiple medication doses were missed over the course of the last year. This poses a potential health, safety and personal risk to residents 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: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
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