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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 02:46:14 PM

Unsubstantiated


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
05/20/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220520092033
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:
01:23 PM
MET WITH:Richard Rubio (by phone)/District ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff locked resident out of facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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, “Staff locked resident out of the facility.” It was discovered through interviews that at approximately 11:00pm on 05/18/2022 that Client 1 (C1) was in the back yard area of the facility, yelling that they were, cold and locked out of the facility. I was determined through interviews that the reporting party could only hear C1 and did not have visual contact of C1 for the RP to determine which client was screaming in the back yard of the facility and if they were in fact, “locked out”. In interviews of Staff 1, 2, and 3 (S1, S2, and S3). S1-3 all confirmed that C1 was in the back yard yelling by choice of C1 and was not locked out with several doors unlocked and one door open during the time in question.

CONTINUED on LIC9909-C
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: 1 of 2
Control Number 29-AS-20220520092033
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
1
2
3
4
5
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32
 There is not enough evidence to support that C1 was locked out of the inside of the facility at approximately 11:00pm on 05/18/2022 at this time, and therefore the allegation of, “Staff locked resident out of the facility.” Is unsubstantiated at this time.
Exit interview. 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: 2 of 2