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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700312
Report Date: 06/21/2024
Date Signed: 06/28/2024 10:48:41 PM

Document Has Been Signed on 06/28/2024 10:48 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PERSON CENTERED SERVICES, INC. #1FACILITY NUMBER:
392700312
ADMINISTRATOR/
DIRECTOR:
MOORE, LAURAFACILITY TYPE:
775
ADDRESS:722 W MARCH LNTELEPHONE:
(209) 466-2448
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 255CENSUS: 117DATE:
06/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:24 PM
MET WITH:Daime HoornaertTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On 6/21/24, Licensing Program Analyst (LPA) Albert Johnson made an unannounced case management visit. The incident on 5/31/2024 was reported to the department on 6/1/2024. LPA spoke with Daime Hoornaert.

LPA reviewed R1's incident report, R1 was waiting outside with staff and other Consumers and was overcome with the heat outside. According to the report R1 was socializing with her peers waiting for the bus to come. R1 was encouraged to come inside or sit in the shade. R1 continued to sit in the sun when staff offered a umbrella R1 appeared to be having a seizure and emergency services were called. R1 was discharged with no new orders.

LPA toured the facility, observed the waiting area and took pictures. The facility has shaded areas and covered seating area for the Consumers when they are waiting outside.

No deficiencies were cited during today's visit.


Exit interview conducted
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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