425802105-3-17-2022-29-AS-KBUY-CCQRUA-20220321131938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:26:52 PM

Unsubstantiated

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
05/20/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20200520081245

FACILITY NAME:	PEOPLE'S CARE LAKE MARIE		FACILITY NUMBER:	425802105
ADMINISTRATOR:	CHARLOTTE ACOSTA HILL		FACILITY TYPE:	735
ADDRESS:	2186 LAKE MARIE DR		TELEPHONE:	(909) 287-3557
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	4	CENSUS: 4	DATE:	03/17/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Belen Gutierrez		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Resident sustained injury while in care.

INVESTIGATION FINDINGS:

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On 3/17/22 at 1:05 p.m., Licensing Program Analyst (LPA) Toan Luong conducted subsequent complaint visit to the facility to deliver final findings. LPA met with Interim-Administrator Belen Gutierrez and explained the purpose of the visit.

On the allegation: Resident sustained injury while in care. It was alleged that on or about 5/8/2020, Client 1 (C1) had dried/crusted blood on C1’s face and scalp. LPA reviewed incident reports, shift logs in Therap, Body/Skin Check documents for C1, and staff Daily Communication Logs. Therap shift logs for the day of 5/6/2020 indicate C1 displayed aggressive behaviors toward C1, staff, and other clients in the facility. The Therap shift log indicates C1 slapped themself with an open hand about 4 times and hit “pretty hard.” The shift notes also stated C1 hit themselves 2 times and banged the back of their head on the kitchen wall. Later C1 banged their head on the wall again and slapped their head 3 more times. According to the Body/Skin Check on 5/6/2020, C1 had resolving scratches on forehead. The Body/Skin Check on 5/7/2020 indicates the forehead scratch as well as a red neck and redness on the back of neck. (Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200520081245

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: 03/17/2022

NARRATIVE

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Daily Community Logs for 5/2/2020 indicates staff noticed a cut on C1’s head and a long scratch under the hair after C1 took a shower and washed their hair. The same injuries are also noted in the Body/Skin Check for 5/2/2020. Daily Therap shift notes or Body/Skin Checks indicate dried or crusted blood on C1’s face and scalp. The shift notes also do not indicate any abuse by staff but do document C1’s self-injurious behavior. Interviews with staff and clients did not indicate any abuse. 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 above allegation is unsubstantiated at this time.

LPA conducted exit interview, emailed a copy of the report and appeal rights to administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

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