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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803541
Report Date: 10/03/2022
Date Signed: 10/03/2022 02:28:51 PM

Document Has Been Signed on 10/03/2022 02:28 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 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:
10/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staff Member, Vanessa Rico-DiazTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at People's Care Rolling HIlls for the purpose of conducting a Case Management-Incident inspection. LPA met with Staff Member, Vanessa Rico-Diaz, and was granted access into the facility. Licensed Psychiatric Tech, Amanda Simmons arrived 30 minutes later.

During the Case Management-Incident, LPA received an incident report dated for October 1, 2022 indicating that a client was left at a medical appointment unsupervised. LPA reviewed Client #1's file and observed the client cannot be out in the community unsupervised (See LIC 809D).

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided to the Licensed Psychiatric Tech, Amanda Simmons.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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 10/03/2022 02:28 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/03/2022 at 01:40 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 ROLLING HILLS
FACILITY NUMBER: 486803541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
80078

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80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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Plan of Correction (POC) will include training for all staff regarding Responsibility to provide Care and Supervision. In addition, Administrator shall provide a written statement on future compliance as it relates to this regulation will be met moving forward
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This requirement was not met as evidenced by:

Based off an observation of the Physicians Report dated for September 16, 2020 it is noted that the client cannot be out in the community unsupervised, but was left at a medical appointment unsupervised. This presents an immeidate health, safety and personal rights risk to the clients in care.
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Plan of Correction due on October 4, 2022.

Proof of Training due on: October 7, 2022

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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