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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802105
Report Date: 07/31/2023
Date Signed: 07/31/2023 12:18:23 PM

Document Has Been Signed on 07/31/2023 12:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:REA BONNER HALLMONFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 4DATE:
07/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rea Hallmon, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management - Incident visit regarding 2 Serious Incident Reports (SIR) from the facility received on 07/25/2023. Today’s visit was conducted on-site in collaboration with a Tri-Counties Regional Center representative. On 07/25/2023, the facility submitted 2 SIRs and 2 Reports of Suspected Dependent Adult/Elder Abuse (SOC 341). The 1st SIR documented that on 7/21/2023, Staff member #1 (S1) stated that Client #1 (C1) had been left in a facility van unsupervised by Staff member #2 (S2) for a period no less than 3 hours in length with no food or water. The back window of the van was rolled down after C1 had been in the van alone and unsupervised for at least 1 hour. This occurred away from the facility at//near the personal residence of S2 with relatives of S2 periodically walking to the van to verbally abuse C1. The 2nd SIR documented that on 7/24/2023, Staff member #3 (S3) had witnessed Staff member #4 (S4) using improper restraints on C1, tying C1 to a chair. The accusation stated that S4 did this multiple times on an ongoing basis. The LPA received a cross report from Adult Protective Services (APS) on 07/28/2023 as well as photographic and video evidence of the incidents from the facility on 07/31/2023 via Tri-Counties Regional Center. During today's visit, the LPA interviewed facility clients, Staff member, the Administrator, and requested documents pertinent to the investigation. During the course of the Case Management visit today the LPA and Tri-Counties Regional Center Representative received information and investigated 2 additional SIRs regarding improper restraint used on Client #2 (C2) on 6/20/2023 and 7/28/2023. On 6/20/2023, C2 stated they were held down in a prone position for no more than 10 minutes by S3. On 7/28/2023, LPA received an SIR that stated S3 had been verbally abusive to clients in the facility. During today's visit, the LPA contacted the Human Resources (HR) of the facility. HR stated they had re-submitted the 6/20/2023 SIR with additional information and that they would email the LPA further information about the SIR. Further investigation is required before final findings are delivered. During today's Case Management Visit, administrator had an appointment for a client and was forced to leave prior to the LPA obtaining a signature on the Case Management Report.

No health and safety hazards noted at this time, and no citations were issued. Exit interview conducted. Copy of the Report issued to the facility. Administrator signature on file

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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