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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:13:14 PM

Document Has Been Signed on 03/30/2023 05:13 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: 5DATE:
03/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Rudi OtaniTIME COMPLETED:
11:59 AM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced case management visit regarding an incident which took place on 3/26/2023. LPA met with House Manager Rudi Otani and explained the reason for the visit.

LPA Camara interviewed staff 1 (S1) and client 1 (C1) starting at 10:45 a.m. On 3/26/23 C1 eloped from the facility sometime between approximately 8:30 p.m. and 8:45 p.m. At that time the facility census was five; three clients on the permanent side and two clients on the crisis side.

C1 could not say why they eloped from the facility. C1 stated they left through the rear door and climbed the fence near the basketball court to get out. C1 stated they went to the lookout area down the road and was found by a Sheriff deputy. S1 stated they believe C1 was triggered by another individual being able to leave to see their family and C1 was not able to see their own family.

According to the facility agreement with Tri-Counties Regional Center, there should have been a minimum of two staff on the crisis side as both clients require 1:1 staffing and there should be a minimum of two staff on permanent side anytime they have two are more clients on that side. .

On 3/26/23 there were only two staff at the facility when there should have been four. They had someone call out on the crisis side and they did not have enough staff to cover the permanent side as one of their staff is currently on leave. The administrator Daniela Mosquera is trying to hire more staff but it has been difficult to find qualified people.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and the report and appeal rights sent to administrator via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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Document Has Been Signed on 03/30/2023 05:13 PM - It Cannot Be Edited


Created By: Teresa Camara On 03/30/2023 at 11:56 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE'S CARE GOODENOUGH
FACILITY NUMBER: 565802410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/03/2023
Section Cited
CCR
85065.5

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85065.5 Day Staff-Client Ratio (a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.
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Administrator will update the schedule with the required number of direct care staff on each shift and send the new schedule to CCL by 4/3/2023 close of business
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This requirement is not met as
evidenced by: Based on observation and records, the licensse did not comply with the section cited above as there were not enough staff working to meet TCRC staffing requirements, which poses a potential heatlh, safety and personal right risk to persons 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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