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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208825
Report Date: 03/19/2024
Date Signed: 03/19/2024 10:51:09 PM

Document Has Been Signed on 03/19/2024 10:51 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PEOPLE'S CARE DAMSENFACILITY NUMBER:
547208825
ADMINISTRATOR:GAMEZ-PLACENCIA, YADIRAFACILITY TYPE:
735
ADDRESS:6502 W DAMSEN AVETELEPHONE:
(559) 627-1281
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: DATE:
03/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:District Manager, Jose Marquez
Regional Manager Mauricio Villatoro 		TIME COMPLETED:
03:01 PM
NARRATIVE
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On 03/19/24, Licensing Program Analysts (LPAs) L. Salazar and S. Doucette arrived at the facility unannounced to conduct a case management visit based on incidents received. LPAs were greeted by district manager and Staff S1 , stated the purpose of the visit and were allowed entry into the facility.

LPA Salazar received multiple incident reports stating R1 and R2's medications were not delivered. Administrator took R1 and R2 to Emergency room on multiple occasion's for medication refill.

Based on the information received and per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D.

An exit interview was conducted with district manager. A copy of this report and appeal rights were discussed and provided at the time of visit. A plan of correction was developed by licensee and reviewed with LPA.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 03/19/2024 10:51 PM - It Cannot Be Edited


Created By: Lisa Salazar On 03/19/2024 at 02:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PEOPLE'S CARE DAMSEN
FACILITY NUMBER: 547208825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
80075(a)(2)

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(a) The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients...
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Licensee has contracted with a new pharmacy locally and conducted training on medication protocol. Administrator is currently on Administrative leave. POC Cleared
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This requirement was not met as evidenced by incident reports stating medications were not delivered and residents were taken to hospital for doses on more than one occasion.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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