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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:42:26 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
07/07/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220707115225
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:MARIA DRUMMONDFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator / Leonardo Peredia TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items.

INVESTIGATION FINDINGS:
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 At 11:30am on 09/22/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to issue final findings to this complaint on the allegations listed above. LPA met with Alonzo Ventura, who called House Administrator Leonardo Peredia who arrived at approximately 12:00 pm.

As to the allegation of, “Staff did not safeguard resident's personal items.” It was discovered through interviews, admission, and documentation that C1 had been provided at least two single units hearing aids (right ear only) by F1 in May of 2019 upon C1’s admission to the facility. Documentation provided by the facility did not show that the facility inventoried the high valued items in C1’s inventory check list as required by regulations. Interviews with Staff 1-3 stated that C1 would often take out or refused to wear hearing aide, confirming that facility had accepted responsibility of hearing aids. Staff 1-3 also indicated that C1 would take out the hearing aides while in the facility van during transportation.

CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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-20220707115225
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: 09/22/2022
NARRATIVE
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 According to Staff 4 in an interview on 06/12/2022, stated that it is believed that C1 possibly threw the heading aide out of the Van window during travel and did know where the hearing aid was tossed out of the van and therefore did not know where to look for the hearing aide. The facility failed to provide inventory documentation of the hearing aides that were in trust of the facility and facility staff, nor did they produce an incident report of the lost hearing aid. Based on interviews, admission and documentation, the allegation of, “Staff did not safeguard resident’s personal items.” Is substantiated at this time.

Exit interview, citation issued, report singed, appeal rights and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220707115225
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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2022
Section Cited
CCR
80026(h)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents.(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care,
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Facility will provide updated client items inventory forms for all clients in care to LPA via Email (mark.jeffries@dss.ca.gov) by October 5, 2022.
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including, but not limited to the following:...
This requirement was not met by evidence of accepted and list high value hearing aid for C1, and not safegauading which puts client in potential danger.
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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: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3