425802105-9-20-2023-29-AS-BPHS-CVUUGW-20230920153501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802105
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:35:30 PM

Document Has Been Signed on 09/20/2023 03:35 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 MARIE		FACILITY NUMBER:	425802105
ADMINISTRATOR:	REA BONNER HALLMON		FACILITY TYPE:	735
ADDRESS:	2186 LAKE MARIE DR		TELEPHONE:	(805) 314-2093
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY: 4		CENSUS: 2	DATE:	09/20/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Rea Hallmon, Administrator		TIME COMPLETED:	03:45 PM

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On 09/20/2023, 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. On 07/25/2023, the facility submitted an incident report with attached Report of Suspected Dependent Adult/Elder Abuse (SOC 341). The incident report documented that on 07/21/2023, an off-duty Staff member of the facility witnessed Client #1 (C1) alone in the facility van while parked in front of Staff Member #2 (S2’s) home over a period of three (3) to four (4) hours. The incident report stated videos and photographs had been taken of the incident. Through interview by LPA, Staff Member #1 (S1) stated that C1 had been left in a facility van unsupervised by 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 in the driveway of the personal residence of S2 with relatives of S2 periodically walking to the van to verbally abuse C1.

On 07/28/2023, LPA received a cross report from Adult Protective Services (APS). On 07/31/2023, LPA received photographic and video evidence of the incident from the facility. LPA interviewed facility clients, Staff members, the Administrator, and requested documents pertinent to the investigation. On 08/15/2023, LPA contacted Human Resources (HR) of the facility. HR provided LPA with additional information regarding the incident. On 08/18/2023, LPA received additional video and picture evidence of the alleged incident occurring. Photographic and video evidence obtained by LPA verifies through timestamps the alleged length of time C1 was left in the facility van by S2. On 08/18/2023, S2 was interviewed by Tri-Counties Regional Center. S2 reported that they took C1 into their home on 07/21/2023. S2 admitted to transporting multiple residents to their personal home and/or on their personal errands. S2 stated that they heard “someone” laughing while C1 was left unsupervised in the facility van on 07/21/2023. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 MARIE	FACILITY NUMBER: 425802105
	VISIT DATE: 09/20/2023

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S2 also stated that on 07/21/2023, C1 indicated to S2 that they needed to use the restroom, but this was not believed to be true by S2. Subsequently C1 soiled themselves and required bathing by S2 in their personal residence.

Video and photographic evidence indicates C1 was observed to be neglected while in care by being left unsupervised in the facility van at S2’s personal residence on 07/01/2023. Additionally, indications of personal rights abuses including interference of daily living functions of C1 are supported through interview testimonial evidence collected. At this case management visit the facility will be cited with a Type A deficiency for Personal Rights, Title 22 (22 CCR) Division 6, Chapter 1 Section 80072(a)(3).

Tri-Counties Regional Center (TCRC) is currently monitoring compliance with a Corrective Action Plan implemented by TCRC through scheduled and unannounced visits to the home as well as other correspondence with the home’s administrator. This is due to a number of Case Management incidents, including the incident taking place on 07/21/2023 described in this report.

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: 09/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2023 03:35 PM - It Cannot Be Edited

Created By: Brian Phillips On 09/20/2023 at 10:27 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: 09/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	Section 80072(a)(3) Personal Rights. (a) Each client...personal rights include the following: (3) Free from…humiliation, intimidation, ridicule, coercion, threat, mental abuse, interference with daily functions: eating, sleeping, toileting; withholding shelter, clothing, medication...	1 2 3 4 5 6 7	The administrator and all staff will refrain from transporting residents to their personal homes or on their personal errands. Licensee will provide LPA with evidence of Client Personal Rights Training for all Staff.
	8 9 10 11 12 13 14	This requirement was not met based on interviews and record review; licensee did not comply with section cited above when staff member kept client unsupervised/neglected in facility van at staff member’s home 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: 09/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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