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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 02/01/2024
Date Signed: 02/01/2024 11:14:27 AM

Document Has Been Signed on 02/01/2024 11:14 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEOPLE'S CARE GOODENOUGHFACILITY NUMBER:
565802410
ADMINISTRATOR:DANIELA MOSQUERAFACILITY TYPE:
735
ADDRESS:2591 GOODENOUGH RDTELEPHONE:
(805) 524-5617
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 6CENSUS: 6DATE:
02/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Daniela MosqueraTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara and Valeria Conway conducted a Case Management - Deficiencies visit due to deficiencies observed during a complaint investigation visit (complaint number 29-AS-20240130110843). LPAs were joined by Tri-Counties Regional Center Quality Assurance Specialists (QAs) Liz Aced-Arnett and Patrick Brown. LPAs explained the reason for the visit. LPAs and QAs initially met with staff and later with the administrator Daniela Mosquera.

At 9:50 a.m. LPAs and QAs conducted a brief facility tour. At 9:55 a.m. LPAs and QAs observed there was not enough food at the facility to meet the needs of clients. There was a nearly empty carton of milk, some frozen meat, a few apples, onions, and a few small potatoes. There was not enough fresh food to meet the regulatory requirements. The non-perishable food normally used by clients needs to be replenished, however the facility does keep a supply of emergency food. Administrator indicated they were going to get food today. Administrator stated that due to the monthly food budget they had to wait until the first of the month.

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: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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Document Has Been Signed on 02/01/2024 11:14 AM - It Cannot Be Edited


Created By: Teresa Camara On 02/01/2024 at 10:44 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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
85076(d)(1)

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85076 Food Service (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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Administrator will purchase food for the facility and send LPA photos of the food purchased and a copy of the receipt on or before 2/2/2024.
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This requirement is not met as
evidenced by: Based on observation, the licensse did not comply with the section cited above as there was not enough food to meet 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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024


LIC809 (FAS) - (06/04)
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