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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005277
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:33:58 AM

Substantiated


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. #3FACILITY NUMBER:
397005277
ADMINISTRATOR:CHERYL ELLIOTTFACILITY TYPE:
775
ADDRESS:651 NORTH CHEROKEE LN., STE. ETELEPHONE:
(209) 466-2448
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:95CENSUS: 66DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Deanna Smith, Program DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not prevent client from sustaining a sunburn while on an outing
Staff did not properly supervise clients while on an outing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Renee Campbell arrived unannounced on 10/25/23 at 9am to complete an investigation of the above-mentioned allegations. LPAs met with Deanna Smith, Program Director and Shelly Bray, 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.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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: 10/25/2023
NARRATIVE
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Regarding “Staff did not prevent client from sustaining a sunburn while on an outing” LPAs obtained information through interviews that some residents used the sunscreen spray on themselves at day program, others stated they used sunscreen prior to arriving to the day program and others did not use it at all. The investigation revealed that residents R1, R8, R11, S5, R12, S2 all had sun burns although some may have reapplied sunscreen during the day. No staff urged residents to take a break in the shade. Some residents were without direct staff supervision. S2 also stated that everyone got a little sunburned but medical attention was not necessary except for R1. R1s information was revealed during a meeting. LPAs observed that R1-R6 reside in a residential facility, while R7-R12 are independent and reside with family. LPAs observed through interviews that the facility staff offered sunscreen before and during the trip. However, staff did not make sufficient attempts to guide residents to reapply sunblock, suggest or provide head coverings or redirect residents to shaded areas.
Regarding “Staff did not properly supervise clients while on an outing” LPAs conducted interviews of 9 of 12 residents and S1-S5. The investigation revealed that the facility and a sister facility joined in the outing. During the outing, residents were allowed to choose their groups to spend the day with. All the groups were to meet back at the chosen area to have lunch. There was a group of 4 residents of which 2 were not able to leave unassisted per the physician report (LIC602). This group did not have staff with them as they traveled around the amusement park. Another 2 residents of which 1 is not able to leave unassisted was using the buddy system, did not have staff present. The Physician report states that residents are not to leave unassisted, they all were accompanied by a person(s) who did not need assistance but residents are not to serve as staff. Residents that cannot leave unassisted, must be accompanied by staff.
Civil Penalties will be issued be issued on 10/25/23. See Form LIC421IM.
Based on interviews with staff and the administrator confirming that allegations were true, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 6, deficiencies are being cited on the attached LIC-9099D. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided.
Civil Penalties will be issued be issued on 10/25/23.
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2023
Section Cited
CCR
85075
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Health-Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical ... needs.
This requirement was not met as evidenced by:
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Licensee agrees to conduct an in-service training with staff to develop a plan and interventions staff can use to ensure that residents do not become sunburned during future outings. A statement of correction will be submitted by
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Based on interview and record review, the licensee failed to develop and implement a plan which ensured that assistance is provided to the clients in meeting their medical needs to avoid sunburns. This poses an immediate health, safety or personal rights risk to residents in care.
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plan of correction date on 11/01/23 via email to LPA Renee Campbell. Proof of staff training for the cited section will be completed and a signature sheet of all staff who attended will be submitted to LPA Renee Campbell after training is finished vie email renee.campbell@dss.ca.gov
Type A
11/01/2023
Section Cited
HSC
1569.312(e)
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Basic services requirements (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
This requirement is not met as evidenced by:
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Licensee agrees to conduct in-service training with staff to go over sun protection and create a sun protection plan. Proof of staff training for the cited section will be completed and a signature sheet for staff will be submitted to LPA Renee Campbell via email by 11/01/23.
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Based on interview and record review, the licensee failed to monitor residents to ensure their general health and safety which poses an immediate health, safety or personal rights 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3