425802105-5-9-2022-29-AS-KBUY-CEDUYX-20220513160042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802105
Report Date: 05/09/2022
Date Signed: 05/09/2022 03:09:39 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
11/06/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20201106142705

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: 4	DATE:	05/09/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jennifer Morales		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Client has inadequate record keeping

INVESTIGATION FINDINGS:

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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 reviewed included Therap Logs from August 2020 through November 2020 and Individual Service Plan – Quarterly Report 3 2020 (ISP) dated 12/22/2020.

Allegation #1 Client has inadequate record keeping
LPA reviewed ISP dated 12/22/2020. At the bottom of page 6 of the ISP, “A sleep study was completed and People’s Care is currently awaiting the results. Still having difficulty sleeping. As of December 2020, C1 hasn’t’ slept for a full night. C1 typically falls asleep around 7pm and is awake by 9pm . C1 wil go back to sleep around 10 pm and up by 12am. (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 5

Control Number 29-AS-20201106142705

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

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(Pg2)
A nightly sleep log is kept and is attached to this report.” A sleep log was not attached to the report. LPA requested logs. Log was not produced. LPA reviewed Therap Logs for October 2020 and November 2020. Therap Logs only tracked behavior and did not fully track sleep patterns. The ISP is incomplete as documents were missing from the service plan. Based on record review, the allegation "the facility did not have adequate client record keeping" is substantiated.
LPA issued citation 9099-D, conducted exit interview, emailed 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: 2 of 5

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
11/06/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20201106142705

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: 4	DATE:	05/09/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jennifer Morales		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff failed to follow physician's orders regarding client
Staff failed to ensure client is sleeping properly

INVESTIGATION FINDINGS:

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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 reviewed included Therap Logs from August 2020 through November 2020 and Individual Service Plan – Quarterly Report 3 2020 (ISP) dated 12/22/2020.

Allegation #1 Staff failed to follow physician's orders regarding client
It was alleged that the facility was not following the physician's order of using a CPAP machine to assist Client #1 (C1) to breath and sleep. It was also alleged that C1 was not receiving a foot ointment as prescribed. LPA reviewed Therap log entries for November 2020. Therap log entry 11/28/20 2-10 p.m. reported (Continued 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: 3 of 5

Control Number 29-AS-20201106142705

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

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(Pg 2)
"C1 stop being resistive after being redirected several times took C1's bedtime meds and temp went to bed laying on the wedge for breathing refused to put on masked." On 11/27/20 2-10 p.m. shift entry reported "C1 was prepped for bed C1 did that with out any incidents wedge was put for C1 breathing refused to put on mask at 9 C1 took C1's bedtime meds and temp was put to bed." Similar entries were reported on 11/24/20, 11/21/20, 11/20/20, 11/19/20, 11/18/20, 11/14/20, 11/10/20, and 11/7/20. It is the personal right of the client to reject services. C1 has the right to refuse services. The facility allowed C1 to exercise C1's personal rights by allowing C1 to refuse.
LPA interviews reveal that C1 will take off CPAP mask after a period of time due to lack of conformability. Staff assist C1 in putting on the CPAP mask.
LPA reviewed Medication Administration Record (MAR) for 12/2/20 - 12/31/20 for C1. Although the page was missing the left side of the scanned print, LPA was able to identify the start date of the prescription as start date of 12/1/20, stop date as 12/31/20, and words, "Apply to feet twice daily." Entries for the 8 a.m. and 9 p.m. were marked off as being given to C1. Based on record review and interview, the allegation "Staff failed to follow physician's orders regarding client" is unsubstantiated.
Allegation #2 Staff failed to ensure client is sleeping properly
LPA interview reveals that C1 does not always have a consistent sleeping schedule. C1 may sleep at times outside of the 10 p.m. - 6 a.m. window. As a result, C1 may be awake during those hours. Interviews also reveal that C1 is not able to sleep on back due to sleep apnea.
LPA reviewed Therap log entries for November 2020. Therap log entry 11/28/20 2-10 p.m. reported "C1 stop being resistive after being redirected several times took C1's bedtime meds and temp went to bed laying on the wedge for breathing refused to put on masked." On 11/27/20 2-10 p.m. shift entry reported "C1 was prepped for bed C1 did that with out any incidents wedge was put for C1 breathing refused to put on mask at 9 C1 took C1's bedtime meds and temp was put to bed." Similar entries were reported on 11/24/20, 11/21/20, 11/20/20, 11/19/20, 11/18/20, 11/14/20, 11/10/20, and 11/7/20.
Therap log entry 11/29/20 2-10 p.m. "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" LPA found other Therap log entries of C1 sleeping outside of 10 p.m. - 6 a.m. window. C1 has the personal right to choose sleep schedule. Facility staff are providing a wedge pillow to C1 in order for C1 not to sleep on C1's back but at an angle. Based on interview and record review, the allegation "Staff failed to ensure client is sleeping properly" is unsubstantiated. LPA conducted exit interview with House Manager, emailed a copy of this report along with appeal rights to the faciltiy.

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 5

Control Number 29-AS-20201106142705

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 B 05/17/2022 Section Cited CCR 85068.3(a)	1 2 3 4 5 6 7	85068.3 Modifications to Needs and Services Plan (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.	1 2 3 4 5 6 7	Facility has agreed to review and udpate service plan for clients and send confirmation that service plan is accurate to LPA by 5/17/22.
	8 9 10 11 12 13 14	This requirement was not met as evidence by, LPA reviewed ISP and did not have available sleep log listed in the ISP which poses a potential health, safety, or personal rights risks to persons 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: 5 of 5