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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 06/03/2022
Date Signed: 06/03/2022 02:41:53 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
05/23/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220523135538
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:RICHARD RUBIOFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
06/03/2022
UNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Richard Rubio (by phone)/District ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility improperly restrained client.

INVESTIGATION FINDINGS:
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 At 2:30pm on 06/03/2022, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to deliver final findings to the complaint allegations listed above. LPA arrived at the facility, announced who he was and the reason for the visit. LPA met with Richard Rubio (by phone)/District Manager, Maria Drummond/Administrator and Jane Libbe to delivered final finding to this complaint.
As to the allegation of, “Facility improperly restrained client.” It was discovered through interviews, documentation, and admission that on the date of May 5th, 2022, at approximately 3:00pm A restraint was preformed of Client 1 (C1), involving Staff 1, 2, 3 and 4. (S1, S2, S3 and S4). I was discovered through admission on the interview conducted at 1:05pm on 05/11/2022 of S2 that S2 held the legs of C1 during the restraint on 05/11/2022. S2 stated that they had not received any training for restraint of clients at that time and up to the time of the interview. S2 also stated that the arms of the client were placed behind their back in a “handcuff position” and that C1’s body weight was supported by the bed and not by the staff involved in the restraint and feet were either held or dangling off the bed. S4 stated to Vince
CONTINUED ON LIC9909-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
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 4
Control Number 29-AS-20220523135538
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
VISIT DATE: 06/03/2022
NARRATIVE
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Figueroa (VF) of Tri Counties Regional Center (TCRC) on 05/31/2022 interview that C1’s hands were behind their back and body was supported by the bed. S4 stated they did not have any CPI training prior to the restraint although there is a CPI training card for S4 dated 03/25/2022. S4 denied having CPI training to VF of TCRC. Additionally, there was no required Serious Incident Report (SIR) filed with Community Care Licensing Department (CCLD) of the restraint performed on 05/11/2022. Because the position of the body of C1 during the restraint, with hands behind the back, and body on the bed while feet were off the floor was not a CPI restraint technique; and S2 was involved in the hold with no restraint training and no documentation of training, and the admission of S4 having stated they had not received CPI training, the allegation of, “Facility improperly restrained client.” Is substantiated at this time.

Exit interview. Citations issued, appeal right provided report signed and copy provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
05/23/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220523135538

FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:RICHARD RUBIOFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
06/03/2022
UNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Richard Rubio (by phone)/District ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility denied client access to telephone.
INVESTIGATION FINDINGS:
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 As to the allegation of, “Facility denied client access to telephone.” It was discovering through interviews and documentation that an “after hours call” was made by C1 to Stephanie Young Consultants crisis line and during the call S5 had taken the phone away from C1. C1 was interviewed on 05/24/2022 at 2:38pm by LPA and VF of TCRC, C1 was asked to explain what happen without any promoting and did not indicated that they were denied a phone call at any time or were cut off from the use of the phone at any time: C1 was asked if they had ever had the phone taken from them by staff in the middle of a phone call, C1 denied having any staff take the phone away during a phone call. C1 was asked of the specific phone call to the allegation and C1 denied having the phone taken away during that specific phone call. LPA and VF of TCRC interviewed S1, S2, S3, and S5 and all denied they saw or limited access of C1 to the phone at any time. Therefore, at this time there is not enough evidence to support the allegation of, “Facility denied client access to telephone.” and is unsubstantiated at this time.

Exit interview, report signed and copy provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220523135538
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: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited
CCR
85102(a)(7)
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Emergency Intervention Prohibitions
(a)The following emergency interventions shall not be used on a client:
(7)Manual restraint with the person’s hands held or restrained behind the person's back
This requirement was not met as evidenced by:
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Peoples Care will ensure that all staff that are scheduled will have proper and certified hold and restraint training by a certified instructor in a certified course, such as CPI for example. Copies of all such training shall be submitted by email on or before 06/17/2022 to mark.jeffries@dss.ca.gov
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Based on interviews, documentation and admission, the licensee did not ensure all staff were properly trained, which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
06/17/2022
Section Cited
CCR
85102(a)(8)
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Emergency Intervention Prohibitions
(a)The following emergency interventions shall not be used on a client:(8)Any manual restraint technique in which a staff member places pressure on a person's back or places his or her body weight
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Peoples Care will ensure that all staff that are scheduled will have proper and certified hold and restraint training by a certified instructor in a certified course, such as CPI for example. Copies of all such training shall be submitted by email on or before 06/17/2022 to mark.jeffries@dss.ca.gov
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 against the person's torso or back: This requirement was not met as evidenced by: Based on interviews, documentation and admission , the licensee did not ensure all staff were properly trained, by restraining client on bed with feet
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suspended or held, which poses an immediate health, safety and personal rights risk to residents in care.
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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4