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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803540
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:14:42 PM

Document Has Been Signed on 07/28/2023 05:14 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:ASHLEY JOHNSONFACILITY TYPE:
735
ADDRESS:707 MORNING SUN CTTELEPHONE:
(707) 449-3935
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Amanda Simmons, Lead StaffTIME COMPLETED:
05:25 PM
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On 7/28/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by staff, Esther Jalloh. Administrator, Ashley Johnson was contacted and notified of the visit. The facility currently provides care for 4 clients, 2 of which were attending day program and two of which present in the facility at the time of visit. Upon arrival LPA observed client (C1) leave the facility from the side gate then (C1) begin walking on the sidewalk. Staff (S1) was immediately observed walking out of the front door after noticing C1 had left the facility. C1 walked across the street but had been in line of sight. C1 had walked approximately one block from the facility and returned. However, LPA found that only one staff was present at the initial time of arrival and C1 requires 1:1 ratio care, meaning that one additional staff is required to provide care for a second client that was also in the facility. Lead staff, Rachel Wright and Amanda Simmons had arrived later during LPA's inspection. Facility is currently undergoing staff shortages but is in the process of hiring additional staff and are partnered with Maxim staffing agency.

LPA continued with a tour of the facility with staff; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/13/2023. Smoke and carbon monoxide detectors were interconnected tested throughout the facility and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. Water was measured at faucets accessible to clients and measured between 114.4 and 114.8 degrees F which is in regulation.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SUN
FACILITY NUMBER: 486803540
VISIT DATE: 07/28/2023
NARRATIVE
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All client’s bedrooms have lighting & appropriate furnishings with bedrooms well maintained and cleaned by staff. Client's (C1) mattress and bedframe have recently been replaced due to damage to C1's prior furnishing. LPA observed furnishings located in the garage and side yard. Administrator confirmed that a service has been scheduled to remove the unneeded items. LPA toured the backyard and found window screens in good repair and emergency exits to be free from obstructions.

Administrator, Ashley Johnson's Administrator Certification 6049075735 is currently active until 2/6/2025.

LPA requested the following documents be sent to CCL by COB 8/28/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance


Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/28/2023 05:14 PM - It Cannot Be Edited


Created By: Dominic Tobola On 07/28/2023 at 04:39 PM
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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
HSC
1569.269(a)(6)

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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by:**
Based on interviews with Admnistrator and staff, LPA found that client (C1) requires
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Administrator agrees to provide a written paln of action on how they will ensure sufficient staffing for all clients including C1's 1:1 ratio level of care. Written plan of action and LIC500 Personnel Report with staffing hours and coverage are to be submitted to CCLD by POC date 8/4/2023.
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1:1 staffing ratio. Upon observation only one (1) staff (S1) was present at the time of LPA arrival and two (2) clients under supervision. This poses and a potential 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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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