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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803541
Report Date: 09/16/2021
Date Signed: 09/16/2021 02:01:20 PM

Document Has Been Signed on 09/16/2021 02:01 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PEOPLE'S CARE ROLLING HILLSFACILITY NUMBER:
486803541
ADMINISTRATOR:LAND, LORRINEFACILITY TYPE:
735
ADDRESS:4219 ROLLING HILLS LNTELEPHONE:
(951) 255-1727
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lorrine Land, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced Case Management- Incident inspection and met with Administrator, Lorrine Land. LPA arrived to facility and contacted Administrator. Administrator and clients were in an outing and later arrived. The purpose of these case management inspections were to follow up multiple self reported incidents reports submitted to Community Care Licensing (CCL).

First incident, 8/26/21, facility reported C1's AWOL incident. C1 returned to facility the same day of incident. Facility searched premises and contacted: Police, District Manager, CCL and North Bay Regional Center (NBRC). During visit LPA Lopez requested documents and took statements from Administrator.

Second incident, facility reported C1's inappropriate behavior incident on 8/27/21. During visit LPA Lopez gathered records, took statements from Administrator. Facility has been in contact with Police, District Manager, CCL and NBRC.


No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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