425802105-4-13-2022-29-AS-KBUY-CDR365-20220422175747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 04/13/2022
Date Signed: 04/13/2022 02:22:26 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
08/13/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20200813092521

FACILITY NAME:	PEOPLE'S CARE LAKE MARIE		FACILITY NUMBER:	425802105
ADMINISTRATOR:	CHARLOTTE ACOSTA HILL		FACILITY TYPE:	735
ADDRESS:	2186 LAKE MARIE DR		TELEPHONE:	(805) 934-0220
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	4	CENSUS: 2	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Maria Drummond		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff are not assisting resident with hygiene needs
Facility staff did not ensure that resident's medical equipment is working properly

INVESTIGATION FINDINGS:

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On 4/13/22 at 11:05 a.m., Licensing Program Analyst (LPA) Toan Luong conducted subsequent complaint visit to the facility to deliver final findings. LPA met with Interim Administrator Maria Drummond and explained the purpose of the visit.

LPA Luong conducted interviews with staff and clients from 3/11/22 through 4/12/22. LPA reviewed documents pertinent to the investigation. Documents included Individual Program Plan (IPP) dated 10/16/2017, 4/1/2019, and 9/8/2020, Therap Notes for the month of February 2020, March 2020, and August 2020 which is the facility documentation on clients, and Indvidual Service Plan (ISP) Quarterly report dates 3/30/2020 and 6/8/2020.

Allegation #1
Facility staff are not assisting resident with hygiene needs.
(Continued 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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 3

Control Number 29-AS-20200813092521

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: 04/13/2022

NARRATIVE

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(Pg2) LPA reviewed IPP dated 9/8/2020. In the IPP, it is written that C1 "requires assistance with maintaining C1's personal care and completing daily living or recreational activities. It is important that staff do not do for C1, rather learn what C1 can do for C1 and encourage C1 to do so, then teach - motivate - encourage to increase C1's level of independence. If C1 begins to display challenging behaviors use the behavioral strategies noted in C1's support plan." "People's Care to support and encourage C1 to ensure C1's teeth are brushed on a daily basis." Support plan is also referred to as the ISP. LPA reviewed IPP dated 10/16/2017 with end date of 10/31/2020. IPP reports that C1 "will continue to live independently with necessary supports." "C1 relies on C1's parent and C1's SLS provider to assist C1 in obtaining, receiving and maintain all medical, dental and psychological appointments." IPP does not elaborate on other dental and hygiene needs. LPA reviewed IPP addendum start date 4/1/2019. IPP has no updates to dental nor hygiene needs.

LPA reviewed ISP dated 3/30/2020 and 6/8/2020. ISP reports under section, "Taking care of self," that C1 "needs assistance in the shower with physical and verbal prompts." "C1 is an active participant in C1's ADL, C1 has become more independent and is requiring less prompting than in the past."

Interviews with staff reveal that staff assist with hygiene needs such as showering and brushing teeth but do not brush C1's teeth, but the facility plan is to promote independence. As such it is the responsibility of C1 to perform brushing owns teeth. Interviews also reveals that a nurse will visit the facility up to three times a week to perform other hygiene tasks such as clipping nails and shaving leg hair.

Therap notes for the evening of 3/9/2020 document that C1 refused to brush teeth. Notes recorded by staff varies as some notes will be more detailed than others. IPP dated 9/8/2020 reports that staff received training on 8/20/2020 on entering support plan data into Therap. Therap notes for the month of February, March, and August 2020 also documents that staff assist with showering and cleaning after C1.
Based on interview and record review, there is not a preponderance of evidence the above allegation is or is not valid, therefore the allegation is deemed to be unsubstantiated

Allegation #2 Facility staff did not ensure that resident's medical equipment is working properly. It was reported that C1's hearing aids were not working properly.
Interviews among clients and staff reveals that C1 will wear a hearing aid but will remove it and throw it.
(Continued on 9099-C)

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20200813092521

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: 04/13/2022

NARRATIVE

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(Pg3) Sometimes causing the hearing aid to break. LPA reviewed Individual Service Plan dated 6/8/2020. Under the communication section. ISP reported that C1 "will put on the hearing aid for a maximum average of one hour and then will take it out. C1 also has a history of throwing C1's hearing aid, causing them to break."
Interviews also reveal staff are able to change out the batteries, but one staff was not trained to on how to detect if the hearing aid was working. Other staff would be able to determine if the hearing aid was low on battery by listening to it for any indicators of low battery such as beeping. It was also reported by staff that C1 has lost hearing aid outside the facility at a day program.

IPP dated 10/17/2017 reports that if C1 "also has hearing issues and needs to be wearing C1's hearing aid as tolerated. C1 keeps one hearing aid at home and another is kept at program. If C1 does not have C1's hearing aid in staff will need to make sure C1 can hear them." "C1 has two hearing aids and 1 hearing aid is supposed to stay at home and the other is supposed to remain at day program. This has been an issue in the past and hearing aids have been sent back and forth from programs and have been lost." IPP dated 9/8/2020 reports that the the responsible party will provide batteries once current supply reaches 10.

Based on interview and record review, there is not a preponderance of evidence that the above allegation did or did not occur, therefore the allegation is deemed unsubstantiated.

Exit interview conducted and this report was emailed to the administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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