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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 05/09/2022
Date Signed: 05/10/2022 09:15:18 AM

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
10/01/2020 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20201001145054
FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:CHARLOTTE ACOSTA HILLFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 934-0220
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer MoralesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication.
Resident's diapering needs were not met.
Staff did not give resident access to resident' personal items
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Toan Luong conducted subsequent complaint visit to the facility to deliver final findings. LPA met with House Manager Jennifer Morales and explained the purpose of the visit.

LPA conducted interviews with staff and clients from 3/11/22 through 3/17/22 and on 4/28/22. LPA reviewed documents pertinent to the investigation from 4/25/22 through 5/9/22. Documents included incident report(s) submitted to Community Care Licensing, Therap Logs, quarterly Individual Service Plan for July 2020, September 2020, and Physicians Report from August 2020 through October 2021.

Allegation #1 Staff mismanaged resident's medication.
Community Care Licensing received an incident report that stated a medication error occurred on 6/14/2020 at 7 a.m. It was reported that Staff (S) discovered Client #3 (C3) did not have medication Levothyoxine provided to C3 for self-administration. (Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
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 8
Control Number 29-AS-20201001145054
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: 05/09/2022
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
26
27
28
29
30
31
32
(Pg2)
Staff #8 (S8) had marked in the Medication Administration Records that medication was provided. S8 also conducted 2nd medication check as well. Based on record review, the allegation Staff mismanaged resident’s medication is substantiated as the facility self reported the incident.

Allegation #2 Resident's diapering needs were not met.
It was alleged that staff were not changing Client #1’s (C1) diaper after C1 soiled diaper. The reporting party stated that there was a day when C1 was found wearing soiled diaper. This incident occurred as staff shift was changing. The reporting party also reported that C1’s room and bed had smearing of feces. LPA interviews reveal that C1 has reached into C1’s diaper with C1’s hands to check if diaper had been soiled. As a result, C1’s hands would be dirty, and C1 would run hand along various surfaces such as walls, bed, and other body parts. Interviews among staff reveals that C1 is able to communicate when C1 has soiled self. Staff would assist C1 in changing into fresh clothing and diaper. Staff are also able to identify when C1 has dirtied self through smell and observation.
LPA reviewed Therap Logs from August 2020 through November 2020. Logs do not report that C1 displayed this behavior of reaching into diaper. Therap Logs mentions few cleaning after C1 but does not specify the events surrounding the cleaning. Therap Log for 8/3/20 2-10 p.m. shift reported, “This staff left the med room with C1’s afternoon medication shortly after 3 pm. This staff located C1 in the restroom. C1 was undressed sitting on the toilet. No staff was present. C1’s clothes and underwear were on the floor. A large amount of feces was observed by this staff inside the underwear. C1 had dried stool smeared on C1's face, on C1's fingers and hands, on C1's back, and in C1's peri area. The stool was dried on parts of C1's thighs, legs, and feet. This staff cleaned up C1 up as C1 spit, hit, and kicked at this staff numerous times.” It should be noted that prior shift was a 6 a.m.to 2 p.m. and would be responsible for assisting clients cleaning up after waking up. C1 will wear a diaper overnight but not during the day. It is unknown how long C1 remained in current condition when p.m. staff found C1. Therap log entry 11/29/20 2-10 p.m. shift reported "was good all day. dont know if C1 is getting sick or not but C1 was asleep when i got to work at 2 and then C1 slept almost the whole day C1 woke up around 830 C1 had poop in C1 diaper so i changed C1 sat C1 on the toilet and C1 pooped again i cleaned C1 up and got pjs on C1." It is not reported which shifts C1 will wear a diaper. Other entries reports staff do clean after C1. Based on Therap log entry for 8/3/20 2-10 p.m. shift, the allegation Resident’s diapering needs were not met is substantiated.
(Continued on 9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20201001145054
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: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited
CCR
80075(b)
1
2
3
4
5
6
7
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidence by incident report submitted to CCLD reported that staff discovered medication was not provided to client the following day
1
2
3
4
5
6
7
All staff received medication training on 6/24/20. Training log will be submitted to LPA.
8
9
10
11
12
13
14
which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
05/10/2022
Section Cited
CCR
85078(a)(1)
1
2
3
4
5
6
7
85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidence by record review, a Therap entry reported that client was found with dried
1
2
3
4
5
6
7
Facility will have a separate log to document assistance with changing client into clean brief and/or underwear. Document will be submitted to LPA by 5/9/22
8
9
10
11
12
13
14
feces in parts of the cilent's body after the morning shift ended, the facility did not assist cilent with hygiene needs, which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
10/01/2020 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20201001145054

FACILITY NAME:PEOPLE'S CARE LAKE MARIEFACILITY NUMBER:
425802105
ADMINISTRATOR:CHARLOTTE ACOSTA HILLFACILITY TYPE:
735
ADDRESS:2186 LAKE MARIE DRTELEPHONE:
(805) 934-0220
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:4CENSUS: 4DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer MoralesTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not intervene in inappropriate interactions between residents.
Staff did not give resident access to use the telephone.
Staff coerce resident(s).
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Toan Luong conducted subsequent complaint visit to the facility to deliver final findings. LPA met with House Manager Jennifer Morales and explained the purpose of the visit.

LPA conducted interviews with staff and clients from 3/11/22 through 3/17/22 and on 4/28/22. LPA reviewed documents pertinent to the investigation from 4/25/22 through 5/9/22. Documents included incident report(s) submitted to Community Care Licensing, Therap Logs, quarterly Individual Service Plan for July 2020, and September 2020.

Allegation #1 Staff do not intervene in inappropriate interactions between residents.
It was alleged by the Reporting Party (RP) that staff will allow clients to continue to aggress on each other, and staff do not intervene. Therap Log created on 11/30/20 for 2-10 p.m. shift reported,
(Continue on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20201001145054
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: 05/09/2022
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
26
27
28
29
30
31
32
(Pg2)
“when they returned they ate dinner thats when C4 and C3 had some words over wasting food C4 was the aggressor and followed C3 into the kitchen where C4 suppose to have hit C3 a couple of times staff called to C4 to stop which C4 did and went to C4’s room there was no more incidents.” On 8/10/20 2-10 p.m. shift, “ C1 had several behavior incidents this evening mostly at staff YO RD ME and peer C3 C1 did screaming spitting hitting and being self abusive C1 was redirected several times for these behaviors by staff by C1 became more aggressive…” On 8/22/20 2-10 p.m. shift, “C1 was very aggressive towards staff and C1’s peers spitting and throwing C1’s fork at C2 C1 was also observed hitting and kicking at staff BS C1 was redirected for these behaviors.”
LPA reviewed incident reports August 2020 through November 2020 received by Licensing. Documents reported that when clients aggress on another client, staff redirect clients elsewhere.
Therap Log and Incident report for 9/19/20 reported that C3 and C4 engaged in altercation where C4 entered C3’s room and aggressed towards C3. Staff removed C4 from the room.
LPA interviews reveal that staff redirect clients when clients are aggressing on each other verbally or physically. Staff do not allow clients to continue aggression towards each other. Clients will be redirected to other areas of the house or staff will attempt to stay between clients when possible. Based on record review and interviews, there is not sufficient evidence to prove the allegation did occur. The allegation, “Staff do not intervene in appropriate interactions between residents” is unsubstantiated.

Allegation #2 Staff did not give resident access to use the telephone.
It was alleged that staff do not provide clients access to the telephone. LPA interview reveals that clients have access to the phone. Some clients will contact 9-1-1 for nonemergency related issues. Majority of staff interviews does not provide an account of client being denied access to the telephone. There was an instance where a client was provided a cellphone from People’s Care day program. There may have been a misunderstanding to whom the cellphone belongs to. After the day program closed, the cellphone was removed from the client and returned to the day program.
LPA reviewed Therap log and Incident report for 9/19/20. Both documents reported that C3 contacted crisis support and 9-1-1. Based on interviews and record reviews there is insufficient evidence the allegation, "Staff did not give resident access to use the telephone," occurred and is unsubstantiated.
(Continued on 9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 29-AS-20201001145054
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: 05/09/2022
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
26
27
28
29
30
31
32
(Pg3)
Allegation #3 Staff coerce resident(s).
It was alleged that staff were requiring clients to do chores to receive items.
LPA interview reveals that clients are not required to do chores but are encouraged to do so. LPA interviewed clients. There was not a consensus that clients were coerced into doing chores.
LPA reviewed Therap log entries and was unable to find mentioning of chores. Based on interview, there is insufficient evidence that the allegation "Staff coerce resident(s)" occurred and is deemed unsubstantiated.

LPA conducted exit interview with the House Manager, emailed a copy of this report along with appeal rights to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20201001145054
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: 05/09/2022
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
26
27
28
29
30
31
32
(Pg3)
Allegation #3 Staff did not give resident access to resident' personal items
It was alleged that staff withheld client’s personal belongings. The belonging in question was in regards to Client #3's (C3) cigarettes.
Interviews among staff reveal that the majority of staff were limiting the number of cigarettes C3 could have in a day. Most of the staff cited it was the order of the psychiatrist.
Therap Log for 9/19/20 6 a.m. – 2 p.m. shift reported, “the staff mentioned that C3 next cigarette will be at 2 pm as C3 made an agreement to smoke only once every shift.” It should be noted C3 should still have access to personal belongings until a doctor's order was in place.
LPA reviewed Physician's order 4/29/21 and 10/28/21. Both orders have an entry for 10/29/20 that stated, "Medical order to limit cigarette intake secondary interfering with C3 antipsychotic medications. Limited to 3 cigarettes per day, one in the AM and one in the PM and a third at C3's discretion. LPA reviewed Physician's order 8/13/20. The 10/29/20 entry was not found on this document. This complaint allegation was received prior to 10/29/20 and C3 was not yet restricted from accessing C3's cigarettes. C3 cigarettes were C3's belongings. Based on interviews, some staff had not worked at the facility after 10/29/20 as significant events occurred, but staff were unaware events. Staff may have limited C3's cigarettes prior to an official physican's order. Based on interview and record review, the allegation "Staff did not give resident access to resident' personal items" is substantiated.
LPA issued citation on 9099-D, conducted exit interview with House Manager, and emailed a copy of today's report to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20201001145054
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: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited
CCR
85072(b)(6)
1
2
3
4
5
6
7
85072 Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights. (6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidence based off interview and record review, staff were limiting client’s belonging
1
2
3
4
5
6
7
Staff will start in-service for personal rights training by 5/10/22. LPA will receive proof of training for all staff once completed.
8
9
10
11
12
13
14
prior to a doctor’s order was in place which poses an immediate health, safety, or personal rights risk to person 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8