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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 12/22/2022
Date Signed: 12/22/2022 04:08:16 PM

Document Has Been Signed on 12/22/2022 04:08 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:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Tanya KramerTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 8:48 a.m. This annual had a specific emphasis on infection control practices and procedures. This facility's perimeter is fully fenced and gated. LPA was at the front gate ringing the doorbell and then honking the car horn for approximately 10 minutes before the House Lead - staff 1 (S1) opened the gate so LPA could enter the premise. S1 explained that the doorbell on the gate sometimes does not work. S1 stated the administrator was already on her way to the facility as they had a staff call out. LPA explained the reason for this visit. The administrator arrived at 9:58 a.m. and LPA explained the reason for the visit.

The LPA, along with S1, toured the physical plant areas inside and outside at approximately 9:00 a.m. to ensure there were no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms for resident use – 4 (four) are private rooms on the permanent resident side of the house; the other two private rooms are located in a locked crisis area for temporary residents.

RESTROOMS: There are 3 (three) restrooms for resident use. All restrooms are clean and sanitary and in operating condition. LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Water temperature averaged 118.2*F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating areas and dining room furniture was observed to be in good condition. LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke and carbon monoxide detectors were tested and functioned properly. The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool surrounded by a tall fence with a locked gate.

Continued on LIC809C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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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: 12/22/2022
NARRATIVE
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MEDICATION: Medication was observed in a locked cabinet near the entryway where visitors are checked for symptoms of COVID-19.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and water. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of


Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.

1 (one) citation was issued during today’s visit. Exit interview conducted. A copy of the report was provided via email to the administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2022 04:08 PM - It Cannot Be Edited


Created By: Teresa Camara On 12/22/2022 at 10:10 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: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited

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80087 Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above as the front gate was inaccessible to visitors since the doorbell on the gate was inoperable, which poses a potential health, safety or personal rights 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: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022


LIC809 (FAS) - (06/04)
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