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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 03:51:23 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
12/30/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20211230155656
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:GUADALUPE RAMIREZFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 3DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Leonardo Peredia/AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility did not seek resident timely medical attention.

Facility staff left resident unattended in the hospital emergency room.
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, “Facility did not seek resident timely medical attention.” It was discovered through documentation and interviews that, on 12/28/2021 according to facility incident report dated 12/30/2021, that C1 got up from a watching TV and complained of foot pain and was unable to walk. Facility incident report and C1’s responsible party (P1) both confirmed the facility had contacted C1’s responsible party at 4:16pm on 12/28/2021 to notify of C1’s injured status. C1’s responsible party did not hear the voicemail until approximately 11:00pm on 12/28/2021 according to P1. Incident report states C1 could not bear weight on foot and could only walk when
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 5
Control Number 29-AS-20211230155656
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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by staff. Due to not being contacted by responsible party, S1 decided to monitor condition of C1 through the PM and overnight (NOC) shifts to monitor for C1’s “if condition worsens”. C1 was unable to walk on their own at 4:16pm on 12/28/2021 and remained unable to walk for over 14 + hours. At approximately 6:51am on 12/29/2021, facility chose to seek medical attention for C1’s foot injury after contacting P1. Facility could have sought medical attention for C1 when the condition was first reported by C1 when C1 complained of injury and was observed by staff, as incident report states, not to be able to walk or bear their own weight on foot. As a result, C1’s condition worsened and C1 had to be taken to the hospital by ambulance on 12/29/2021 at approximately 6:51am. Based on documentation, and interviews staff did not seek medical attention for C1 in a timely manner and the allegation of, “Facility did not seek resident timely medical attention.” Is substantiated at this time.

As to the allegation of, “Facility staff left resident unattended in the hospital emergency room.” It was discovered through documentation and interviews that the facility incident report dated 12/30/2021, states around 8:30am on 12/29/2021, administrator noticed LPT in the facility and asked why they were not at the hospital with C1. LPT stated they “were not needed” (at the hospital with C1). Administrator sent another staff to the hospital to assist C1, who arrived at the hospital at approximately 10:30am. Based on interviews, physicians report and documents, C1 would be unable to safely remain in the hospital independently and communicate effectively with hospital staff. C1 was unsupervised in the hospital for at least 2 hours. Based on the information obtained, the allegation of, “Facility staff left resident unattended in the hospital; emergency room.” is substantiated at this time.

Exit interview, citations issued, report signed, 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 5
Control Number 29-AS-20211230155656
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 A
09/23/2022
Section Cited
CCR
80075(a)
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80075(a) Health Related Services. Each client shall receive necessary first aid and medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. Staff did not seek medical
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Facility will schedule and conduct training for all staff on identifying medical emergency's. Proof of scheduling and staff training will be provided to LPA by email (mark.jeffries@dss.ca.gov).
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attention for S1 in a timely manner which posed a serious risk for client in care.
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Type A
09/23/2022
Section Cited
CCR
80078(a)
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80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. Facility staff left C1 unattended in the emergency room which posed a serious risk for client in care.
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Facility will provide a written procedure for shadowing clients to emergency room which shall include staff training by 09/23/2022 to LPA by email (mark.jeffries@dss.ca.gov).
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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 5
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
12/30/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20211230155656

FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:GUADALUPE RAMIREZFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 3DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Leonardo Peredia/AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility did not provide hospital emergency personnel a current list of resident's medications.

Facility staff did not adequately communicate with resident's responsible party.
INVESTIGATION FINDINGS:
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 As to the allegation of “Facility did not provide hospital emergency personnel a current list of resident's medications.” Based on documentation and interviews it was discovered that, on 12/29/2021 around 6:51am, staff were preparing to take C1 to the hospital due to injured foot. According to facility incident report dated 12/30/2021, administrator provided staff Licensing Psychiatric Technician (LPT) copies of paperwork to give to emergency personnel, including C1’s medication list (MAR) and face sheet. LPA obtained copies of the (MAR) and emergency face sheet that was allegedly provided to emergency personnel on 12/29/2021 when C1 was put in the ambulance. Interviews of LPT and S1 suggest that the face sheet and MAR was given to emergency personnel at the time C1 left in the ambulance . Incident report dated 12/30/2021 states, the face sheet and MAR for C1 was to be given to emergency personal. Because there were no staff supporting C1 in the emergency room, we cannot be sure if C1’s face sheet and MAR were available to the Emergency Room personnel. LPA reviewed C1’s hospital discharge paperwork, which does not mention whether or not documentation was available.
CONTINUED on LIC9099-C
Unsubstantiated
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: 4 of 5
Control Number 29-AS-20211230155656
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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Staff were unable to remember whether the paperwork was given to the emergency personnel, but the SIR states it was printed out to be given to the personnel. There is insufficient to prove this allegation occurred. Therefore “Facility did not provide hospital emergency personnel a current list of resident’s medications.” and is unsubstantiated at this time. LPA recommends that the facility ensure they have a consistent procedure in place for providing client’s face sheet and current MAR to emergency personnel.

As to the allegation of “Facility staff did not adequately communicate with resident's responsible party." Based on documentation and interviews, it was discovered that, the reporting party’s concern was that C1’s responsible party was only notified one time about C1 expressing pain and unable to walk. Facility incident report and C1’s responsible party both confirmed the facility contacted C1’s responsible party at 4:16pm on 12/28/2021. C1’s responsible party did not hear the voicemail until approximately 11:00pm on 12/28/2021 according to documentation and interview of R1. The facility contacted C1’s responsible party timely, and according to regulations. Based on the documentation, interviews and admission, the allegation of, “Facility staff did not adequately communicate with resident’s responsible party.” is unsubstantiated at this time.

Exit interview, report signed, 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: 5 of 5