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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:39:46 PM

Document Has Been Signed on 08/04/2023 12:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE GOODENOUGHFACILITY NUMBER:
565802410
ADMINISTRATOR:TANYA KRAMERFACILITY TYPE:
735
ADDRESS:2591 GOODENOUGH RDTELEPHONE:
(805) 524-5617
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 6CENSUS: 6DATE:
08/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rudi OtaniTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management – Incident visit for two incidents which took place on 8/2/23 and 7/19/23. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA and QAS met with house manager Rudi Otani and explained the reason for the visit.

Interviews were started with staff 1 (S1) at 10:20 a.m. and staff 2 (S2) at 10:51 a.m. LPA and QAS toured the crisis side of the facility inside and outside at 10:40 a.m. Documents were reviewed and obtained regarding the 8/2/23 incident at 11:10 a.m. Administrator Daniella Mosquera was not able to make it to the facility during LPA's visit but briefly discussed both incidents with LPA and QAS at 12:10 p.m. Client 1 (C1) was not interviewed (regarding the 7/19/23 incident) as C1 was asleep. Client 2 (C2) (regarding incident on 8/2/23) was not at the facility during the visit.

Administrator agreed to put in a maintenance order to ensure there are no rocks over the size of a quarter on the crisis side of the facility and a chime alarm will be placed on the gate which leads to the driveway from the crisis side of the facility. These requests are due to the incident that occurred on 8/2/23 in which C2 threw a rock at Client 3 (C3) and injured C3.

Administrator and house manager were not able to locate all of the therap notes from the 7/19/23 incident. Administrator will locate the notes and send them to LPA and QAS. LPA will return at a later date to further address the 7/19/23 incident.

During this visit, there were no health and safety concerns identified. No deficiencies were observed during today's visit.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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