425802105-9-22-2022-29-AS-KBUY-CJMV7Y-20220926161154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:46:01 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
06/07/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20220607084612

FACILITY NAME:	PEOPLE'S CARE LAKE MARIE		FACILITY NUMBER:	425802105
ADMINISTRATOR:	MARIA DRUMMOND		FACILITY TYPE:	735
ADDRESS:	2186 LAKE MARIE DR		TELEPHONE:	(805) 314-2093
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	4	CENSUS: 3	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Administrator/Leonardo Peredia		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was left in a soiled diaper for an extended period of time.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 Administrator Leonardo Peredia Housewho arrived at approximately 12:00 pm.
As to the allegation of, “Resident was left in a soiled diaper for an extended period of time.” It was discovered through documentation, interviews, and photographic evidence that on the date of 05/31/2022, Client 1 (C1) had been photographed with an extremely drooping (approximately 6”-8”), over-soiled, incontinent care garment by Staff 2 (S2), time the photograph taken is unknown. Facility records show that there were two staff working the day shift from approximately 8:00am to 4:10pm (S1) and 4:40pm (S2). The evening staff arrived at 3:40pm (S3) and 4:00pm (S4). In an interview S4 stated that S2 and S3 were arguing over who would change C1 from 4:01pm until approximately 4:40pm.

CONTINUED on LIC9099-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: 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-20220607084612

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This time frame places C1 in a soiled incontinent care garment for a minimum time of 40 minutes. However, the picture taken by S2 suggests that C1 had needed assistance in changing that far exceeded 40 minutes. Due to staff conflict over changing C1, C1 suffered undue neglect for a minimum of 40 minutes according to interviews and documentation. Based on interviews, documentation, and photographic evidence, the allegation of, “Resident was left in a soiled diaper for an extended period of time.” is substantiated at this time.

Exit interview, citation issue, report signed, appeal rights and report emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
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-20220607084612

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 80072(a)(3)	1 2 3 4 5 6 7	80072(a)…each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, … humiliation, …other actions of a punitive nature, including but not limited to: interference with the daily	1 2 3 4 5 6 7	Facility will conduct new training with all staff on client care, which includes incontinence training. Proof is required to be submitted to LPA by email (mark.jeffries@dss.ca.gov) by 09/23/2022.
	8 9 10 11 12 13 14	living functions, including eating, sleeping, or toileting; … These requirements were not met based on evidence of C1 being in soiled briefs for an unacceptable length of time without proper changing. Which poses a serious health risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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