425802105-6-3-2022-29-AS-KBUY-CGCQYB-20220715123453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 06/03/2022
Date Signed: 06/03/2022 02:50:09 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
05/19/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20220519111029

FACILITY NAME:	PEOPLE'S CARE LAKE MARIE		FACILITY NUMBER:	425802105
ADMINISTRATOR:	RICHARD RUBIO		FACILITY TYPE:	735
ADDRESS:	2186 LAKE MARIE DR		TELEPHONE:	(805) 314-2093
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	4	CENSUS: 4	DATE:	06/03/2022
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Richard Rubio (by phone)/District Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident wandering away from facility.

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, “Lack of supervision resulting in resident wandering away from the facility.” It was discovered through interviews, documentation, and video evidence that on 05/19/2022 at approximately 10:27am that Client 1 (C1) entered a neighbor’s home without invitation, unaccompanied by any staff. Staff 1, 2 and 3 (S1, S2, and S3) were interviewed on 05/24/2022 from 12:22am-2:18pm and all indicated that the morning of 05/19/2022 at approximately 10:00am that C1 was in the back yard yelling, all three staff indicated in the interviews that no staff was outside with C1 and C1 was being monitored by the yelling of C1 during that time. Reporting Party (RP) was interviewed on 05/26/2022 at 3:53pm. RP stated that a resident (C1) from the facility across the street (425802105) entered their home through the office
CONTINUED on LIC9909-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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)

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Control Number 29-AS-20220519111029

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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door, once in the home the RP address C1 by stating, “I’m sorry, you’re in the wrong house.” RP stated that they had to grab a hold of C1 to walk them out of the RP’s home. Once past the door of the RP’s home with C1, the RP walked across the street and notified staff of the facility that the client had entered their home without any staff present and was still in their front yard. Once the RP notified staff at the facility that C1 had entered the RP’s home staff then walked across the street to redirect C1. The RP contact Santa Barbara County Sheriffs. RP provided video evidence of C1 walking up the RP’s driveway at 10:27am. C1 was not wearing any shoes, moving at a slow pace with irregular gate (limping) and not accompanied by any staff, nor were their staff in the background of the video which faces towards the facility. Staff Only arrived after C1 walked from the back yard of the facility, across the street, up the driveway, into the Rp’s home, then redirected C1 of the RP’s home, walked down the driveway, across the street and notified the staff that C1 was still on RP’s property. Due to the slow pace of C1 from the backyard of the facility, across the street, up the driveway and into the neighbors home, the neighbor redirecting the C1 out of the home, then walking across the street to notify staff, then staff moving across the street to redirect C1 constitutes a significant amount of time that C1 was not supervised by staff resulting in a temporary elopement, therefore the allegation of, “Lack of supervision resulting in resident wandering away from the facility” is substantiated at this time.
Exit interview, citations issued, report signed, appeal rights provided, and copy of report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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)

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Control Number 29-AS-20220519111029

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 85078(a)(1)	1 2 3 4 5 6 7	85078 Responsibility for Providing Care and Supervision (a)In addition to Section 80078, the following shall apply: (1)The licensee shall provide those services identified in the client's needs and services plan as necessary to meet	1 2 3 4 5 6 7	All staff will train or retrain a minimum of 1 hour on Providing Care and Supervision. Additionally, all scheduled staff will train on each Clients needs and services. This shall be documented and submitted by email to mark.jeffries@dss.ca.gov by 06/17/2022.
	8 9 10 11 12 13 14	the client's needs. This requirement was not met based on interviews, observation and video evidence the client was without care and supervision, which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
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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.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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)

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