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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803541
Report Date: 10/24/2022
Date Signed: 10/24/2022 12:37:01 PM

Document Has Been Signed on 10/24/2022 12:37 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:
10/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Stephanie HenryTIME COMPLETED:
01:00 PM
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
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced People's Care Rolling Hills, The for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO) on October 24, 2022. LPA met with Stephanie Henry, and was granted access into the facility.

CCL received an incident report reporting a medication error. The error occurred on October 22, 2022 due to staff member giving medication at the wrong time to Client #1 (C1) (See LIC 809D). Responsible party and prescribing physician were notified of the medication error. LPA obtained copies of the Medication Assessment Record (MAR) for the month of October 2022 for C1 that reflects the said medication error.

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 Administrator 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: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/24/2022 12:37 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/24/2022 at 11:48 AM
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: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075(b)-Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Plan of Correction (POC) will include retraining all staff on medication procedures, proper documentation on the MAR and following physicians prescribing instructions. In addition, Licensee shall provide a self-certification of this regulation and how future compliance will be met.
8
9
10
11
12
13
14
Based on review of incident report, the licensee did not comply with the section cited above due to administering the medication at the wrong time to C1 which poses an immeidate health, safety and personal rights risk to clients in care.
8
9
10
11
12
13
14
POC due on October 25, 2022. Proof of staff training along with sign in sheet due October 31, 2022.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2