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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803540
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:19:16 PM

Document Has Been Signed on 10/14/2022 12:19 PM - 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:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amanda SimmonsTIME COMPLETED:
12:30 PM
NARRATIVE
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While conducting a complaint investigation, LPA followed up on two unusual incident reports submitted to CCL.
Incident 1: C1 left facility without staff knowledge and was found approximately 15 minutes later, walking around the neighborhood. C1 requires constant supervision and is not to be away from the home without assistance. LPA received copies of updated care plan. Facility is working with the regional center to find more appropriate placement for C1.

Incident 2: C2 received a double dose of their evening medication. Staff, S1, did not see that the medication was already given and gave an additional dose. All staff underwent additional medication training. Procedures were updated to ensure medication errors do not occur in the future. This is a repeat violation within a 12 month period. A civil penalty is being issued in the amount of $250.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


This report was reviewed with Amanda Simmons and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2022 12:19 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 10/14/2022 at 10:26 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2022
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.Based on review of incident report, the licensee did not comply with
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Licensee conducted retraining for all staff regarding medication administration on 09/21/2022. POC Cleared at time of visit.
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the section cited above in where 1 of 4 clients did not recieve their medication as prescribed. This poses an immediate health, safety or personal rights risk to clients in care.
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Type A
10/17/2022
Section Cited
CCR80065(a)

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 80065 Personnel Requirements:(a) Facility personnel shall be competent to provide...and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as
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Licensee worked with the regional center and changed protocols for staffing to ensure clients are safe. POC Cleared at time of visit.
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evidenced by: Based on interviews and records reviewed, Licensee did not ensure the amount of staff necessary to meet client needs. This poses an immediate health, safety or personal rights risk to clients in care.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
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