<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803541
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:00:47 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20221003100358
FACILITY NAME:PEOPLE'S CARE ROLLING HILLSFACILITY NUMBER:
486803541
ADMINISTRATOR:HENRY, STEPHANIEFACILITY TYPE:
735
ADDRESS:4219 ROLLING HILLS LNTELEPHONE:
(951) 255-1727
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY:4CENSUS: 4DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff Member, Emmanuel Emmanuel
Licensed Psychiatric Tech, Amanda Simmons		TIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient care and supervision
Staff are violating clients rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at People's Care Rolling HIlls for the purpose of delivering complaint findings. LPA was met at the door by Staff Member, Emmanuel Emmanuel, and was granted access into the facility. Licensed Psychiatric Tech, Amanda Simmons arrived 20 minutes later.

During the course of the investigation, LPA interviewed staff, clients and various outside parties, including but not limited to responsible parties. LPA conducted a tour of the facility and made observations on October 3, 2022 and October 20, 2022.

Complaint alleges insufficient care and supervision. Based on interviews with staff members, clients and review of the video provided, LPA learned that the former staff member was smoking an unknown substance while providing care and supervision to clients in care (See LIC 9099D).

(Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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 3
Control Number 21-AS-20221003100358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ROLLING HILLS
FACILITY NUMBER: 486803541
VISIT DATE: 11/22/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA made attempts to interview the former staff member, but was unsuccessful due to the former staff member not returning phone calls and voice mails.

Complaint alleges Staff are violating clients rights. Based on a review of the termination documents, LPA obtained and reviewed termination documents reflecting that the former staff member was terminated after the allegations came to the facilities attention. LPA learned that the former staff member was terminated for reporting to work under the influence (See LIC 9099D).

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Licensed Psychiatric Tech and appeal rights were emailed to the Administrator along with this report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20221003100358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ROLLING HILLS
FACILITY NUMBER: 486803541
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
1
2
3
4
5
6
7
Plan of Correction (POC) shall include a written statement on how future compliance and training will be met in the future regarding providing Care and Supervision and self-certification.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Based on interviews with staff, clients and review of the video provided, former staff member did not provide the necessary Care and Supervision to clients in care. This is an immiedate health, safety and personal rights risk to the clients in care.
8
9
10
11
12
13
14
Licensee/Administrator shall train ALL staff regarding providing Care and Supervision neccessary to meet the clients needs.
Type A
11/23/2022
Section Cited
CCR
80072
1
2
3
4
5
6
7
80072 Personal Rights

(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations,
1
2
3
4
5
6
7
Plan of Correction (POC) shall include a written statement on how future compliance and training will be met in the future regarding providing Personal Rights and self-certification.
8
9
10
11
12
13
14
furnishings and equipment to meet his/her needs.

This requirement was not met as evidenced by:

Based on a review of the termination documents, facility terminated former staff member due to the allegation(s) and observation of video. This is an immiedate health, safety and personal rights risk to the clients in care.
8
9
10
11
12
13
14
Licensee/Administrator shall train ALL staff regarding Personal Rights neccessary to meet the clients needs.
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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3