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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803540
Report Date: 06/28/2022
Date Signed: 06/28/2022 11:09:18 AM

Document Has Been Signed on 06/28/2022 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PEOPLE'S CARE MORNING SUNFACILITY NUMBER:
486803540
ADMINISTRATOR:HENRY, STEPHANIEFACILITY TYPE:
735
ADDRESS:707 MORNING SUN CTTELEPHONE:
(707) 449-3935
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
06/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Renee DillardTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst Leibert, during the course of a complaint investigation, noted that the Needs and Service Plan of 12/14/2022 for C1 was incomplete and that the facility files contained contradictory information regarding the level of supervision appropriate for C1. Deficiencies are being cited with plan of correction in order to restore compliance.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report left at facility.

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/28/2022 11:09 AM - It Cannot Be Edited


Created By: David Leibert On 06/28/2022 at 10:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PEOPLE'S CARE MORNING SUN
FACILITY NUMBER: 486803540

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2022
Section Cited
CCR
85068.3(a)

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85068.3(a) Modifications to Needs and Service Plan. The written needs and service plan...shall be updated as frequently as necessary to ensure it's accuracy, and to document significant occurrences that result in changes in the client's physical, mental, and/or social functioning.
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Facility Administration will complete a fully executed Needs and Service Plan for C1 that addresses all pertinent needs of C1, including the required staffing requirements and modes of supervision to avoid future incidents involving C1 and facility neighbors and the surrounding properties. Proof of correction by POC date in order to clear deficiency.
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****Based upon the records reviewed, this requirement has not been met as evidenced by: C1's behavior of trespassing on neighboring property is not addressed in the client's needs and service plan. This poses a potential risk to the health and safety of the client and to the facility's standing in the community.
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Type B
07/12/2022
Section Cited
CCR85068.2(b)

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85068.2(b) Needs and Service Plan. If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan…..***Based upon records reviewed, this requirement has not been met as evidenced by: Needs and Service Plan for C1 of 12/14/2022 is not complete or
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Facility Administration will complete a fully executed Needs and Service Plan for C1 that addresses all pertinent needs of C1, including the required staffing requirements and modes of supervision to avoid future incidents involving C1 and facility neighbors and the surrounding Proof of correction by POC date in order to clear deficiency.properties.
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signed by all parties. This poses a potential risk to the personal rights and safety of C1.
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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.
SUPERVISOR'S NAME:Carla Martinez
LICENSING EVALUATOR NAME:David Leibert
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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