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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208825
Report Date: 02/12/2024
Date Signed: 02/12/2024 01:25:05 PM


Document Has Been Signed on 02/12/2024 01:25 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:
02/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Administrator, Yadira Gamez-Placencia and District Manager, Jose Marquez.
TIME COMPLETED:
01:24 PM
NARRATIVE
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On 02/12/2024, Licensing Program Analysts (LPAs) Walton and Salazar arrived unannounced to conduct a case management inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Yadira Gamez-Placencia and District Manager, Jose Marquez.

The purpose of today's visit is to follow up on incident reports that were submitted to the Fresno CCL office.

It was reported that on 02/07/2024, a medication count was conducted and it was found that R1 was missing 8 pills of clonazepam. R1 was admitted to the hospital on 01/30/2024, discharged and readmitted on 02/02/2024, and discharged again on 02/06/2024. Facility staff last conducted a pill count on 02/01/2024 and found 65 pills remaining. On 02/06/2024, a pill count was conducted and 57 pills remained..

On 02/12/2024, facility reported that R1 did not receive a PM medication as ordered. A medication count was conducted on 02/11/2024 and it was found that on 02/10/2024, R1's PM medication was not dispersed.

Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator, Yadira Gamez-Placencia and District Manager, Jose Marquez. A copy of this report was discussed and provided to Administrator, Yadira Gamez-Placencia, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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 02/12/2024 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services: (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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Licensee agrees to submit a written statment detailing the steps the facility will take to ensure the requirements for section 80075(b) are met to the Fresno CCL office by the POC due date.
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Based on record review, the Licensee did not comply with section 80075(b) when facility staff did not assist in administering a medication to R1 as prescribed... which is an immediate health and safety risk to persons in care.
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Type A
02/13/2024
Section Cited
CCR80026(b)

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80026: (b) If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables not handled by a person outside the facility who has been designated by the client or his/her authorized representative shall be handled by the licensee or facility staff, and shall be safeguarded... this requirement was not met as evidenced by:
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Licensee agrees to submit a written statment detailing the steps the facility will take to ensure the requirements for section 80026(b) met to the Fresno CCL office by the POC due date.
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Based on interview and record review, Licensee did not ensure the requirements for seciton 80026(b) were met when the facility did not safeguard R1's medication while R1 was in the hospital... which is an immediate health and safety risk to persons in care.
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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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2