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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 07/12/2024
Date Signed: 07/12/2024 10:47:57 AM

Document Has Been Signed on 07/12/2024 10:47 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE GOODENOUGHFACILITY NUMBER:
565802410
ADMINISTRATOR/
DIRECTOR:		DANIELA MOSQUERAFACILITY TYPE:
735
ADDRESS:2591 GOODENOUGH RDTELEPHONE:
(805) 524-5617
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 6CENSUS: 6DATE:
07/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Daniela MosqueraTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent case management visit to deliver findings for a case management investigation related to an incident report received on 12/28/2022. LPA initially met with facility staff. Administrator arrived at 10:25AM and LPA explained the reason for the visit.

On 12/28/2022, the Community Care Licensing Division (CCLD) received a self-reported unusual incident report (LIC 624) and Report of Suspected Abuse (SOC341) pertaining to Client #1 (C1). C1 reported that their personal rights were violated while at the facility. C1 alleged that they were inappropriately touched by Client #2 (C2) at the facility. On 12/29/2022, the case was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris.

On 01/03/2023, from 11:41am to 12:45pm, Licensing Program Analyst (LPA) Kelly Dulek initiated an unannounced Case Management – Incident visit for an Incident Report received at the Regional Office on 12/28/2022. LPA Dulek arrived at the facility at 11:41am and met with Administrator Tanya Kramer. The incident report indicated that Client #1 (C1) informed their family member that Client #2 (C2) had made unwanted contact with C1 on an unknown date about two weeks prior. C1 indicated they had not told staff at the time of the alleged incident. Facility staff were informed of the alleged incident by C1's family member. During the visit, LPA Dulek along with the Administrator toured the facility at 11:45am. No health and safety concerns were identified during the visit. The LPA also interviewed the Administrator throughout the visit and obtained copies of pertinent documents. The Administrator was informed that the Community Care Licensing Investigations Branch (IB) Investigator Christine Ferris would follow up regarding the incident.

Investigator Ferris conducted interviews on 01/12/2023 with C1; and on 01/17/2023, with Tri-Counties Regional Center (TCRC). In addition, the investigator reviewed facility file documents, including C1 and C2’s Person Centered Individual Program Plan (IPP), and C1’s 90-day Behavior Assessment and Support Plan.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 GOODENOUGH
FACILITY NUMBER: 565802410
VISIT DATE: 07/12/2024
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C1’s IPP listed diagnoses which include Fetal Alcohol Syndrome, ADHD, OCD, Anxiety, Depression, and Bi-Polar Disorder. A review of C1’s 90-day Behavior Assessment and Support Plan, dated 07/06/2022, revealed it is common for Fetal Alcohol Spectrum Disorder (FASD) individuals to confabulate. C1 embellishes facts or verbalizes an untrue story, whether it be intentional or unintentional. According to previous records, C1 has a long history of engaging in fabricating stories and manipulation. C1 is assigned a 1 to 1 staff 24 hours per day.

C2’s IPP, dated 02/04/2021 revealed C2 has an extensive history of maladaptive and dangerous behavior. Per the 02/05/2018 IPP document, these behaviors included stealing, verbal and physical aggression, self-injurious behaviors, inappropriate sexual behavior, false allegations, and intimidation.

During the interview process, C1 stated they had previously dated C2 for two weeks but then broke up. C1 stated there was no trouble with C2 when they broke up, but then C2 just stopped talking to them and has ignored them ever since. C1 stated there have been no issues with C2, C2 has not threatened to harm C1, and has not done anything to harm or hurt C1. C1 denied C2 touched them inappropriately or had tried to touch them inappropriately. C1 stated C2 has never done anything to them that they did not like or did not want them to do. C1 stated they feel safe with everyone who lives and works at the facility.

Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation. C1 denied C2 touched them inappropriately, threatened, or harmed in any manner. Therefore, the allegation “Sexual Abuse: (C1) was touched inappropriately by (C2)” is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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