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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 08/19/2021
Date Signed: 08/19/2021 06:36:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20210728115134
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:CHARLOTTE ACOSTA HILLFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
08/19/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lacey HamsonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has staff working in the facility without California clearance
INVESTIGATION FINDINGS:
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On 8/19/21 at 1:20 PM, LPA Luong conducted an unannounced complaint visit to the facility to deliver final findings of the complaint allegations. LPA met with House Manager Lacey Hemeon and explained the purpose of the visit.
Allegation #1: Facility has staff working in the facility without California clearance.
On 8/3/21, LPA conducted interviews with staff, clients, and administrator on-site at 9:47AM, 9:53 AM, 9:58 AM, 10:24 AM 10:37 AM, 10:45 AM, 11:18 AM, and 1:18 PM on-site. Based on interviews, LPA was able to determine a staff was working at the facility. Staff did not have a California clearance in Guardian, CDSS background check. LPA reviewed Guardian entries and was able to verify individual was not granted a California clearance through Guardian. The above allegation is deemed substantiated at this time. Citation issued on LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 29-AS-20210728115134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE'S CARE LAKE MARIE
FACILITY NUMBER: 425802105
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2021
Section Cited
CCR
80065(i)(1)
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80065 Personnel Requirements (i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law. Based on interviews and record review, the facility failed to have a staff obtained a
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Facility will remove staff from the schedule.
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California clearance granted by the department prior on-site employment.
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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: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC9099 (FAS) - (06/04)
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