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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208876
Report Date: 11/09/2022
Date Signed: 11/09/2022 11:30:11 AM

Document Has Been Signed on 11/09/2022 11:30 AM - 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 NORTH N PLACEFACILITY NUMBER:
547208876
ADMINISTRATOR:JONATHAN ESCOBEDOFACILITY TYPE:
735
ADDRESS:829 NORTH N PLTELEPHONE:
(909) 287-3557
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 4CENSUS: 1DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Jonathan Escobedo, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) L. Cabrera arrived at the facility unannounced to conduct a Case Management Inspection for a Case Management that occurred on 08/15/2022 to follow up on a CPI hold that occurred when Administrator Kristin Ennis was at the facility. Staff Maria Hernandez took Covid 19 pre-cautionaries prior to entry into the facility. Administrator Jonathan Escobedo responded to the facility to assist with the visit.(Note: This incident report was in August 2022; Jonathan was not Administrator at the time of the incident).


LPA L. Cabrera reviewed Staff records for CPI training and client’s records.

Deficiency is being cited on the attached LIC809D.

An exit interview was conducted with Administrator Jonathan Escobedo and a copy of this report and Appeal was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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 11/09/2022 11:30 AM - It Cannot Be Edited


Created By: Lady Cabrera On 11/09/2022 at 11:04 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PEOPLE'S CARE NORTH N PLACE
FACILITY NUMBER: 547208876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited
CCR
85168.3(c)

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85168.3 Manual Restraint or Seclusion Review (c) Documentation of the debriefing meeting in the client's record shall include the findings of the review, any modifications to the client's Needs and Services Plan, and any refusal by the client to participate in the review.
This requirement was not met as evidenced by:
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Administrator shall review Title 22, Division 6, Subchapter 1, Section 85168.3 Manual Restraint or Seclusion Review. LPA provided a copy of the regulation to the Administrator. Administrator shall provide in writing that the regulation has been read and understood by Friday, 11/11/2022.
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Based on interview and review of records, Licensee did not ensure that a debriefing occured and there was no documentation of a debriefing meeting in the client's records, which poses an potential health and safety risk to clients 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


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