<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802105
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:38:26 PM

Document Has Been Signed on 08/15/2023 03:38 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: 3DATE:
08/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rea Hallmon, AdministratorTIME COMPLETED:
03:30 PM
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
On 08/15/2023, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct further investigation and to issue final findings for a Case Management - Incident visit. LPA met with Administrator Rea Hallmon and explained the purpose of the visit.

LPA conducted a previous Case Management - Incident visit on 07/31/2023 in collaboration with Tri-Counties Regional Center in which further investigation was required. LPA and Tri-Counties Regional Center Representative received information/documentation including Incident Reports (SIR) from the facility on 6/20/2023 & 7/28/2023 stating that one staff member had conducted an improper support hold on a resident in care on 6/20/2023. The facility alleged per the SIR that the resident was held face down on the floor in a prone position, with the staff member placing pressure on the resident’s back with their knee and/or placing their body weight against the resident’s torso and back for between 5 to 10 minutes. On 07/31/2023, the Resident stated to the LPA & Tri-Counties Regional Representative that they were held down in a prone position on their stomach by a Staff member for no more than 10 minutes which caused great discomfort and pain. On 08/14/2023, LPA received an email from the facility District Manager. The email indicated the Human Resources (HR) Department of the facility stated the Staff member acknowledged using the improper Crisis Prevention Institute (CPI) hold on the Resident on 06/20/2023. Facility HR stated the Staff member was candid with the internal fact-finding discussion by the facility as to the incident, and promptly acknowledged how the incident happened and evolved into an improper support hold. Additionally, HR stated the Staff member has completed 16 hours of CPI training and has been assessed for physical skills and de-escalation techniques.

At this case management visit the facility will be cited with a Type A deficiency for Emergency Intervention Prohibitions, Title 22 (22 CCR) Division 6, Chapter 6 Section 85102(a)(8).
Exit interview conducted, citation issued, appeal rights and copy of the report provided to the facility Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 08/15/2023 03:38 PM - It Cannot Be Edited


Created By: Brian Phillips On 08/15/2023 at 10:21 AM
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
85102(a)(8)

1
2
3
4
5
6
7
Section 85102(a)(8) Emergency Intervention Prohibitions (a) The Following emergency interventions shall not be used on a client: (8) Any manual restraint technique in which a staff member places pressure on person’s back or places his/her body weight against the person’s torso or back.
1
2
3
4
5
6
7
As a result of this incident, the Staff member has completed 16 hours of CPI training, and has been assessed for physical skills and de-escalation techniques. The Administrator will provide evidence of this to the LPA, and will provide evidence that CPI Training has been scheduled for all Staff by 08/16/2023
8
9
10
11
12
13
14
This requirement was not met based on interviews and record review; the licensee did not comply with the section cited above when one staff member conducted an improper support hold on a resident in care which posed an immediate health and safety risk to residents 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
LICENSING EVALUATOR NAME:Brian Phillips
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2