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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803541
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:14:45 PM

Document Has Been Signed on 09/24/2024 12:14 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/
DIRECTOR:		GARRETT JOHNSONFACILITY TYPE:
735
ADDRESS:4219 ROLLING HILLS LNTELEPHONE:
(707) 447-5317
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
09/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Garrett Johnson, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced at The People's Care Rolling Hills, for the purpose of following-up on an incident report facility submitted to the Regional Office on September 20, 2024. LPA met with Administrator, Garrett Johnson.

CCL received an incident report reporting a medication error. The error occurred on September 19, 2024 due to staff member not giving AM medication 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 September 2024 for C1 that reflects the said medication error.

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.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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 09/24/2024 12:14 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/24/2024 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: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
80075(b)

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80075(b)-Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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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.
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Based on review of incident report, the licensee did not comply with the section cited above due to not administering AM medication to C1 which poses an immediate health, safety and personal rights risk to clients in care.
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POC due on September 25, 2024. Proof of staff training along with sign in sheet due September 27, 2024.

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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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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