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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802105
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:48:18 PM

Document Has Been Signed on 09/22/2022 03:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:LEONARDO PEREDIAFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 3DATE:
09/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH: Leonardo Peredia/AdministratorTIME COMPLETED:
03:34 PM
NARRATIVE
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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 three separate complaints and conduct a case management visit. LPA met with Alonzo Ventura, who called House Administrator Leonardo Peredia who arrived at approximately 12:00 pm.

LPA's requested C1's LIC602 (Physicians Orders) both verbally and written request on six different LIC9099's, dated 05/24/2022, 06/03/2022, 06/14/2022, 07/13/2022, and 08/09/2022. LPA also requested the same form (LIC602) by email to facility interim Administrator Joanna Iniguez on 07/14/2022. As of today 09/22/2022, LPA requested LIC602 for C1 while present at the facility and facility still can not produce documentation. LPA has not received C1's LIC602, a form that is a imperative to have on file at facility for understanding the needs and care for C1 while in care at the facility and requited to have on file at the facility by regulations. LPA spoke with current Administrator about record keeping for clients in care and stressed the importance for having LIC602 and other forms of documentation required by regulations on file at the facility. At this case management visit facility will be cited for not having clients medical assessment, LIC602. (80069(b)(1)).

Exit interview, citation 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/22/2022 03:48 PM - It Cannot Be Edited


Created By: Mark Jeffries On 09/22/2022 at 12:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
80069(b)(1)

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80069 Client Medical Assessment (b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is
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Facility will Administrator will contact C1's mother to request form LIC602 and additionally set up a doctors appointment for an updated LIC602 if the current LIC602 cannot be located, Administrator will keep daily contact with LPA Jeffries untull C1 has LIC602 on file at the facility.
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 also a licensed professional, and the assessment shall not be more than one year old when obtained. Based on multiple requests written/verbal/email to review C1’s LIC602 which has not been file at the facility, which poses a serious risk for clients in care
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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
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


LIC809 (FAS) - (06/04)
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