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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208883
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:03:36 PM

Document Has Been Signed on 04/19/2022 04:03 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 AVENUE 344FACILITY NUMBER:
547208883
ADMINISTRATOR:SMITH, BILLIEJEANFACILITY TYPE:
738
ADDRESS:14453 AVENUE 344TELEPHONE:
(909) 287-3557
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 2DATE:
04/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator BillieJean SmithTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility to conduct a case management inspection regarding an incident that occurred around 2/17/22. LPA met with Administrator BillieJean Smith.

During the course of the Case Management investigation, LPA reviewed records and video that was sent to the Administrator by Staff. Administrator stated the audio recording was submitted on 2/23/22 by Staff but she believes the incident occurred around 2/17/22.

Administrator will submit copies of Staff records/CPI Records and client records.

Deficiencies were cited for Personal Rights. Refer to 809D.

An exit interview was conducted with Administrator and a copy of this report and appeal rights were provided via email to the Administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 04/19/2022 04:03 PM - It Cannot Be Edited


Created By: Shawna Doucette On 04/19/2022 at 01:59 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 AVENUE 344
FACILITY NUMBER: 547208883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2022
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions
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Plan of Correction POC Licensee agrees to complete staff training for Abuse Prevention, Recognizing Abuse and Behavior Support Plans for all staff on 2/24/22 and 2/25/22.

LPA observed copies of training.

POC Cleared during Visit
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of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met evidenced by: Based on interviews and video recording, Licensee did not ensure that C1 was free of intimidation, ridicule and threats by S1 and S2, which poses an immediate 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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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