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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802410
Report Date: 06/22/2023
Date Signed: 06/22/2023 12:56:53 PM

Document Has Been Signed on 06/22/2023 12:56 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:
06/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Daniella MosqueraTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management – Incident visit for an Incident Report received at the Regional Office on 6/4/2023 regarding an incident which took place on 6/3/2023 between client 1 (C1) and client 2 (C2). LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA and QAS met with the current administrator Daniella Mosquera and explained the reason for the visit.

Interviews were started with staff 1 (S1) at 12:20 and C1 at 12:35. C2 was asleep and not available for an interview. Based on the interviews conducted, there were no concerns regarding personal rights or any other violations toward C1 or C2. There were no health and safety concerns identified.

No deficiencies were observed during today's visit.


Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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