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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208877
Report Date: 12/01/2023
Date Signed: 12/08/2023 04:56:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/08/2023 04:56 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 CHAVEZFACILITY NUMBER:
547208877
ADMINISTRATOR:EMILY CARPENTERFACILITY TYPE:
735
ADDRESS:1228 CHAVEZ CTTELEPHONE:
(559) 688-4968
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 4CENSUS: 4DATE:
12/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Regional Director, Mauricio Villatoro
District Manager, Jose Marquez		TIME COMPLETED:
03:15 PM
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On 12/01/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the required annual visit. LPA contacted Administrator on record (ADM), Emily Carpenter, who arrived to the facility shortly after LPA. District Manager (DM), Jose Marquez and Regional Director(RD), Mauricio Villatoro also arrived to the facility. LPA stated the purpose of the visit and was allowed entry into the facility.

LPA requested Individual Performance Plans (IPPs) for all residents in the home. ADM provided 3 out of 4 IPPs at the time of the visit. 2 out of the 3 IPP's were observed to be dated 2022. LPA requested Annual Functional Behavior Assessments (AFBA) for all residents in care. ADM provided 3 out of 4 AFBAs at the time of visit. 3 out of 4 resident's AFBA were observed to be dated 2022.

LPA requested Personnel Report (LIC500) and current staff training for all personnel listed on LIC500. ADM did not provide proof of staff training at the time of visit.

Records review of the facility show there is not a current Administrator Certificate for Emily Carpenter. Certificate expired 10/21/23. There is no record of application sent to CCL for this certificate to be recertified.

LPA toured the facility with RD's and ADM. No resident's were home at the time of the tour. Facility is observed to be a 4 bedroom, 2 bathroom house. The facility was observed to be unclean and in disrepair.

The following observations were made during the tour:

Living Room was observed to have a ripped couch and chair. RD's stated new furniture has been ordered and was scheduled for delivery today.

Dining Room was observed to have a broken window blind, floor tile under the table is scratched and discolored, drill holes in the wall that need filling/repair and reminisce of old stickers are observed on the kitchen cabinet.

Kitchen was observed to have a dust/grease stain on the wall above the exhaust vent, microwave was observed with a broken handle. Refrigerator was observed to be dirty inside and out and the sealing on the fridge door is separating from the door.

(Continued on LIC 809-C1)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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 5
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 CHAVEZ
FACILITY NUMBER: 547208877
VISIT DATE: 12/01/2023
NARRATIVE
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(Continued from 809)
Bathroom # 1 was observed to have a loose water faucet hardware in the sink, light over the toilet area was out, trash can was uncovered without a tight fitting lid, door knob stop on the wall behind the door is cracked , shower liner has mildew at the bottom and walls and baseboards are observed to be dirty and in need of cleaning.

Bathroom # 2 was observed to have a broken stopper in the sink, metal shower rod, shower curtain hook and light fixture are rusted and need replacement. exhaust fan in the bathroom has a layer of dust and is not working at full capacity.

Hallway was observed to have three ceiling lights, all with dirty fixtures. Walls and baseboards are in need of cleaning or repainting. Carbon Monoxide detector on the wall has a layer of dust. Night lights / emergency lighting was not observed in the hallway. LPA observed facility sketch, posted on the hallway wall, to be outdated and missing required information.

Bedroom #2 (Resident R2) - Night stand was observed to be missing a drawer and knobs to the remaining 2 drawers are missing. An ottoman/storage bench was observed to be unsteady and broken, rod for window coverings was bent and not secured to the wall, window blind is broken, there is no closet door, the rod to hang clothes was observed being stored in the closet. Personal lighting was not observed.

Bedroom #3 (Resident R3) - Holes are observed in the walls that need to be filled. Bedroom walls and window track are observed to be dirty and in need of cleaning. Personal lighting was not observed.

Bedroom #4 (Resident R4) - Ceiling fan and window track were observed to be dirty. There is a cable cord on the floor that is not in use and needs to be removed, window covering at the top of the window needs to be provided as the sun shines in R4's eyes while trying to sleep. LPA requested ADM at the previous visit of 10/26/23 to provide a covering for the top window, per R4's request. This verbal request was not completed. Personal lighting was not observed.

LPA toured the backyard of the facility and observed a broken couch, night stand and window blinds that are being stored on the patio. A mop bucket and several mops/brooms were also observed to be stored on the patio. A hose was observed on the patio ground that needs to be removed or hung to avoid a tripping hazard. A broken portable basketball hoop was observed. Outdoor furniture is observed to have a table and chairs, however, the chair cushions/pads were missing and would be required to support the residents in the chairs.
(Continued on LIC809-C2)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023
LIC809 (FAS) - (06/04)
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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 CHAVEZ
FACILITY NUMBER: 547208877
VISIT DATE: 12/01/2023
NARRATIVE
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(Continued from 809-C1)

Based on LPA's observations at the time of visit and in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D.

Due to technical difficulties, an exit interview was conducted via zoom on 12/05/23. Plans of corrections were developed and reviewed with DM and RD and a copy of this report, appeal rights, and signature request was sent via telecommunications 12/07/23.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/08/2023 04:56 PM - It Cannot Be Edited


Created By: Lisa Salazar On 12/03/2023 at 01:06 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 CHAVEZ
FACILITY NUMBER: 547208877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
85064(b)

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85064 Adminstrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by LPAs observation of the expired Administrator Certificate (10/21/23). No documentation was available to be provided evidencing application for recertification has been submitted.
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Licensee will provide proof that Administrator has completed and submitted the required Administrator qualifications or Licensee must appoint a new Qualified Administrator by POC date.
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Type B
12/08/2023
Section Cited
CCR80068.2(b)(1)

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80068.2 Needs and Services Plan
(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.
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Licensee will provide written documentation that an annual IPP review was completed in 2023 or provide document that an IPP review has been scheduled for completion. Licensee will provide LPA with the scheduled date for resident's in care with an outdated IPP by POC date.

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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: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/08/2023 04:56 PM - It Cannot Be Edited


Created By: Lisa Salazar On 12/03/2023 at 01:40 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 CHAVEZ
FACILITY NUMBER: 547208877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by LPA's observation which is detailed in the report.
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Licensee will complete all areas of cleaning listed on the report and send proof via pictures by POC date of 12/08/23. Licensee will also provide written documentation with the dates repairs and/or replacement of broken items will we completed.
Type B
12/08/2023
Section Cited
CCR
85088(c)(3)

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(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility. This requirement was not met as evidenced by LPA's observation of resident bedrooms.
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Licensee will purchase and provide personal lighting in all residents rooms and send proof via pictures by POC date of 12/08/23.
Type B
12/08/2023
Section Cited
CCR80075(a)

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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Licensee will schedule a dental appointment for Resident R1 to receive dental services/treatment by POC date. Proof of scheduling date will be sent via email to LPA by POC date.
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This requirement was not met as evidenced by LPA's observation of R1's teeth and interview with ADM. ADM was unable to provide documentation of R1's previous services and/or a date for future dental services.
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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: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2023


LIC809 (FAS) - (06/04)
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