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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 08/08/2022
Date Signed: 08/09/2022 04:13:32 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
12/06/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20211206165540
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: 3DATE:
08/08/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:House Staff/Alanzo VenturaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff inappropriately touched residents
Staff did not treat resident with dignity
INVESTIGATION FINDINGS:
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 At 11:15am on 08/09/2022, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with House staff Alanzo Ventura and explained the reason for the visit. LPA talked to interm House Administrator Leonardo Peradia by phone.
On 12/06/2021, the Department received a complaint alleging Staff inappropriately touched residents and
Staff did not treat resident with dignity. It was alleged that Staff #1 (S1) inappropriately touched Client #1’s (C1) arm and body blocked Client #2 (C2).
On 12/07/2021, from 9:35am to 12:00pm, Licensing Program Analyst (LPA) Toan Luong conducted the initial 10-day complaint visit. LPA Luong was accompanied by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Vincent Figueroa. The investigation was conducted on-site with Administrators Guadalupe Ramirez and Richard Rubio. During the visit, LPA toured the facility, conducted interviews with staff and clients from 10:00am to 1:15pm, obtained documents pertinent to the investigation, and reviewed video footage of the facility. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
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 3
Control Number 29-AS-20211206165540
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: 08/08/2022
NARRATIVE
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On the allegation: Staff inappropriately touched residents. It was alleged that Staff #1 (S1) hugged and scratched Client #1’s (C1) arm around Thanksgiving 2021. C1 communicated to S1 that C1 did not want to be hugged and said no. Interviews revealed that C1 made a remark that staff heard C1 make a remark for S1 not to touch C1. Different accounts of the incidents were provided in which S1 patted C1 or S1 hugged C1 with one arm over C1’s shoulder and scratched C1’s on the inside of the right arm above the elbow. LPA and QAS observed a small red mark on C1’s arm during an interview. Based on interviews, there is sufficient evidence in which S1 made physical contact with C1 and resulted in C1 being scratched. The allegation “Staff inappropriately touched residents” is deemed Substantiated at this time.

On the allegation: Staff did not treat resident with dignity. It was alleged that S1 body blocked Client #2 (C2). LPA Luong’s interviews revealed that video footage existed in which C2 went to answer the door and S1 allegedly body blocked C2 on 12/01/2021. Staff interviews revealed that clients are capable of answering the door but may require supervision. The facility promotes the clients’ ability to function independently and be able to complete tasks. Another staff was present during the incident but did not witness the body block.

LPA reviewed video footage obtained from the facility. The video is 12 seconds in length. At the 4 second mark, C2 is seen moving from the couch towards the door. S1 is seen leaving from the kitchen and moving towards the door at same time C2 is moving towards the door. At the 6-7 second mark, S1 and C2 reach for the doorknob, but C2 is observed stumbling back 2-3 steps before the door is opened by S1. Based on interviews and observation, S1 blocked C2 from answering the door which resulted in C2 being knocked back. The allegation “Staff did not treat resident with dignity” is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211206165540
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: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons.
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Facility will submit proof of staff training in client personal rights. Submit to CCL by 08/12/2022 to LPA Jeffries by email.
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This requirement is not met as evidenced by:Based on interviews and video footage review, the licensee did not comply with the section cited above. Licensee failed to ensure C1 and C2’s personal rights as S1 did not allow the clients to have personal space, which posed a potential
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 health and safety risk to clients 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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
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