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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803540
Report Date: 10/04/2023
Date Signed: 10/04/2023 01:22:22 PM

Document Has Been Signed on 10/04/2023 01:22 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:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Ashley Johnson, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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LPA Arrived unannounced for the purpose of conducting a case management following up on a self-reported incident involving a physical altercation between a staff (S1) and client (C1) on 9/28/2023. LPA interviewed Administrator and gathered staff (S1) files for department to review. S1 was placed on administrative leave and an internal investigation is currently being conducted for determination of corrective action for S1. Administrator will be providing LPA with documentation once determination is confirmed.

Client C1 was on an outing with staff during the visit but LPA was informed that C1 has not had any significant changes in behavior other than speaking less with staff and clients. C1 had expressed emotional distress to lead staff closer to the date of the incident. Facility is providing additional day outings for C1 to assist with de-escalation and ensuring C1 is able to re-integrate into a comfortable relationship with current staff. The facility failed to ensure the protection of personal right’s for client in care (C1). Deficiency was determined and citation issued under violation of personal rights and Title 22 Regulation. The facility will be implementing an in-person training on client personal rights, de-escalation and managing behaviors and is scheduled on 10/11/2023. Facility Administrator has properly followed up on the incident and ensuring further compliance and safety of clients moving forward.

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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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Document Has Been Signed on 10/04/2023 01:22 PM - It Cannot Be Edited


Created By: Dominic Tobola On 10/04/2023 at 12:53 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: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
800072(a)(3)

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80072(a)(3)Personal Rights - (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Facility failed to ensure client personal rights were protected. Facility has placed S1 on administrative leave and currently holding internal investigaiton with pending corrective actions. Facility has also scheduled an in-person service training for all staff on client personal rights, de-escalation and managing
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This requirement was not met based on**
Physical alteration between staff (S1) and client (C1) resulted in S1 inproperly de-escalating C1 behaviors with S1 reported to have placed thier hands on C1's neck and strike C1. This serves as an immediate health & safety risk to clients in care.
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behaviors. Training will be conducted on 10/11/2023. Administrator to provide copies of signed training for all staff once completed.
Deficiency cleared at the time of visit.

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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: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023


LIC809 (FAS) - (06/04)
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