397005277-10-25-2023-27-AS-KHOS-CX5KFY-20231031075241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005277
Report Date: 09/06/2023
Date Signed: 10/25/2023 11:34:29 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2023 and conducted by Evaluator Renee Campbell

COMPLAINT CONTROL NUMBER: 27-AS-20230829101758

FACILITY NAME:	PERSON CENTERED SERVICES, INC. #3		FACILITY NUMBER:	397005277
ADMINISTRATOR:	CHERYL ELLIOTT		FACILITY TYPE:	775
ADDRESS:	651 NORTH CHEROKEE LN., STE. E		TELEPHONE:	(209) 466-2448
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	95	CENSUS: 70	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Deanna Smith, Program Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not ensure that clients were properly hydrated while on an outing

INVESTIGATION FINDINGS:

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After review by LPM Hodgkins, This report has been amended to correct findings. The third allegation above will remain unsubstantiated.
Licensing Program Analyst(s) Renee Campbell and Victoria Brown arrived unannounced on 9/6/23 at 8am to conduct an investigation of the above-mentioned allegation. LPAs met with Deanna Smith, Program Director and stated the purpose of the visit.

LPAs received a copy of the facility Flex Form, Emergency Identification and Authorization form, Insurance coverage form, Medication list, Physician Report (LIC602), Case Management -Agency Events, Individual Program Plan (IPP) for 12 residents. Community Care Licensing (CCL) received a complaint on 8/29/23 indicating 3 allegations to be investigated. LPAs received information through interviews that the day program and students attended an outing in the community to Concord, CA on 8/26/23. Based on a Google search of AccWeather the weather for the day of the trip was a high of 92 and a low of 59 in Lodi, CA and in Concord, CA a high of 87 and a low of 58 degrees Fahrenheit.

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20230829101758

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PERSON CENTERED SERVICES, INC. #3	FACILITY NUMBER: 397005277
	VISIT DATE: 09/06/2023

NARRATIVE

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Regarding “Staff did not ensure that clients were properly hydrated while on an outing” LPAs obtained information through interviews that staff took a case of water on the trip for resident use. However, residents had a choice of either drinking the water provided or purchasing a drink at the park. LPAs did not obtain any information that any resident obtained or needed to seek medical attention for dehydration.

The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies cited. An exit interview was conducted, a copy of this report was provided.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20230829101758

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PERSON CENTERED SERVICES, INC. #3	FACILITY NUMBER: 397005277
	VISIT DATE: 09/06/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	See 9099C for continuation

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3