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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 03/03/2022
Date Signed: 03/03/2022 04:29:26 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
02/22/2022 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20220222164221
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:GUADALUPE RAMIREZFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 2DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Richard RubioTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility staff do not have adequate training to performed assigned duties.
Facility did not provide services to meet clients' mental health needs.
Facility transport vehicle was not kept clean.
INVESTIGATION FINDINGS:
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On 3/3/22 at 9:40 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced complaint visit to the facility. LPA met with Regional Manager Richard Rubio acting as the facility administrator and explained the purpose of the visit. The facility receives funding from Tri Counties Regional Center (TCRC) and is subject to additional requirements.
Allegation #1
Facility staff do not adequate training to performed assigned duties.
Between 9:40 a.m. and 2:30 p.m., LPA reviewed staff records. Staff #1 (S1) was hired on 11/27/2020 and started working on 12/01/2020. S1 completed Year 1 35-Hour Direct Support Professional Training Class (DSP I) on January 14, 2022 and has not completed Year 2 35-Hour Direct Support Professional Training Class (DSP II). Administrator informed LPA that staff has not completed DSP II. TCRC requires all direct care staff to complete both courses within 12 months upon hire if DSP I was not completed before hire. S1 has DSP II courses scheduled 4/4/22.
(Continued on 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
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 7
Control Number 29-AS-20220222164221
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: 03/03/2022
NARRATIVE
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Based on LPAs record review and interview, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1, Article 06. Continuing Requirements 80065 Personnel Requirements), is being cited on the attached LIC 9099D.

Allegation #2
Facility did not provide services to meet clients' mental health needs.
Between 9:40 a.m. and 2:30 p.m., LPA reviewed staff records and interviewed administrator. Interview with administrator at 2:30 p.m., reveals that there was no Licensed Marriage Family Therapist (LMFT) services provided in the November and December 2021, administrator will be appealing as hours provided by LMFT and Behavior Consultants were not documented, and administrator was informed at 3:40 p.m. by a previous staff that services as contracted. The facility’s plan of operation to meet client’s mental health needs require 4 hours of qualified behavior consultant and 1 hour of LMFT per client each month. Record reviews corroborated administrator’s 2:30 p.m. statement. In addition, in the month of October, 4 out of 4 clients received 1.5 hours with a behavior consultant per LPA record review.
Based on LPAs record review and interview, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6, Article 06. Continuing Requirements 85075 Health-Related Services), is being cited on the attached LIC 9099D.

Allegation #3
Facility transport vehicle was not kept clean
Between 9:40 a.m. and 2:30 p.m., LPA conducted interviews with staff and clients. Interviews with staff reveals that the facility van has not been cleaned and smells of urine. Seats were made from cloth fabric and will absorb smells. Clients may become incontinent during transportation. LPA and administrator inspected the vehicle at 1:40 p.m., administrator stated, “It’s dirty.” LPA asked how the vehicle smelled, and administrator peaked his head inside the vehicle and removed his mask. Administrator was able to identify the smell of urine. LPA observed various light brown marks on the seats about the size of a thumb print. The carpet had various coloration of dark stains. Interviews with other staff reveals that some staff have been able to take the vehicle to a self-service carwash to perform cleaning, detailing, and shampooing of the vehicle, but no receipt of this would be available at the facility. (Continued on 9099C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20220222164221
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: 03/03/2022
NARRATIVE
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The facility policy would have staff report cleanliness daily, administrator check weekly, and a district manager check monthly. The facility is currently undergoing administrator changes and the district manager inspected the vehicle approximately 3 weeks ago and did not observe the vehicle in the same condition.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6, Article 07. Physical Environment 80087 Buildings and Grounds), is being cited on the attached LIC 9099D.

Exit interview conducted, report and appeal rights emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/22/2022 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20220222164221

FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:GUADALUPE RAMIREZFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 314-2093
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 2DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Richard RubioTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Facility transportation was not maintained to operate safely
Facility did not provide client activities
INVESTIGATION FINDINGS:
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On 3/3/22 at 9:40 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced complaint visit to the facility. LPA met with Regional Manager Richard Rubio acting as the facility administrator and explained the purpose of the visit. The facility receives funding from Tri Counties Regional Center (TCRC) and is subject to additional requirements.

Allegation #1
Facility transportation was not maintained to operate safely
Between 9:40 a.m. and 2:30 p.m., LPA obtained receipts of Jiffylube with service date 8/4/21 and 5/18/21. Receipts also indicate the vehicle was serviced on 3/30/21, but the facility did not have a copy of the receipt on file. 5/18/21 service date reveals mileage of 53,337, and vehicle underwent a tire change and balance. Facility’s maintenance procedure would be a notification through the Enterprise fleet services about every 3 months or vehicle light notification. Staff would bring the car in for service. (Continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20220222164221
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: 03/03/2022
NARRATIVE
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LPA interviewed staff who have completed service and confirmed process. The vehicle was serviced on 8/4/21 and had oil service, tire rotation, and wiper blades installed.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation #2
Facility did not provide client activities
Between 9:40 a.m. and 2:30 p.m., LPA conducted interviews with staff and clients. 2 clients were present during the time of the inspection. Interviews with staff and client reveals that clients have physical activities of going out to the park and beach. Clients also have social activities participating together such as bingo, puzzles, and putting on make-up. Clients are asked for their inputs on activities, and clients will respond by wanting and going on a car rides.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

LPA conducted exit interview, emailed report and appeal rights issued to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20220222164221
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: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2022
Section Cited
CCR
85075(b)
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85075 Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met as evidence by record review and interview, LPA found that not enough hours were provided to clients with a licensed mariage therapist and
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LPA discussed with administrator to accurately document behavior consultant and LMFT hours New administrator will review hours before the end of the month to ensure clients receive services.
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behavior consultants from Oct 2021 to December 2021. The licensee failed to comply with the regulation above in 12 counts which poses a immediate health, safety, or personal rights risk to person in care.
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CCR
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20220222164221
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: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2022
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence by interviews and observation, LPA and administrator found the vehicle to be unclean with stains on the seats and floor and
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Administrator scheduled a vehicle cleaning for. Administrator will send invoice to LPA by 3/10/22.
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the vehicle had a urine smell.The licensee failed to comply with the regulation above in 1 count which poses a possible health, safety, or personal rights risk to person in care.
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Type B
03/10/2022
Section Cited
CCR
80065(f)
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80065 Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not met as evidence by record review and interview, LPA
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Administrator has scheduled staff to complete DSP II courses starting April. POC is corrected.
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found one staff without DSP II training completed with 12 months of hire per TriCounties Regional Center requirement. The licensee failed to comply with the regulation above in 1 count which poses a possible health, safety, or personal rights risk to person 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7