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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 01/03/2023
Date Signed: 01/03/2023 12:41:01 PM

Document Has Been Signed on 01/03/2023 12:41 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:
01/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Tanya KramerTIME COMPLETED:
12:45 PM
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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 arrived at the facility at 11:41AM and met with Administrator Tanya Kramer. Entrance interview conducted.

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 by C1's family member, filled out the Incident Report and supporting documents and faxed them to the Regional Office upon learning of the alleged incident.

During today's visit, LPA Dulek along with Administrator toured the facility at 11:45AM. No health and safety concerns were identified during today's visit. LPA also interviewed the Administrator throughout the visit, reviewed and gathered copies of pertinent documents. Administrator was informed that CCLD's Investigations Branch (IB) Investigator Christine Ferris will be following up regarding the incident.

No citations issued during today's visit. IB investigator and/or LPA will follow up at a later date to continue the investigation.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
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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