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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802463
Report Date: 03/20/2023
Date Signed: 03/20/2023 05:11:03 PM

Document Has Been Signed on 03/20/2023 05:11 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 HOWEFACILITY NUMBER:
565802463
ADMINISTRATOR:TANYA KRAMERFACILITY TYPE:
735
ADDRESS:3851 HOWE RDTELEPHONE:
(805) 398-5096
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 6CENSUS: 4DATE:
03/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Belen GutierrezTIME COMPLETED:
01:44 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit to the facility regarding incidents which occurred on 3/7/23 and 3/10/23 regarding Client 1 (C1). LPA was joined by Tri-Counties Regional Center(TCRC) Quality Assurance Specialist (QAS) Liz Aced-Arnett.

During the visit LPA and QAS interviewed staff starting at 9:55 a.m. and 12:29 p.m. and a client at 12:07 p.m. Further investigation is needed. LPA will return at a later date.

A Deficiency was observed and addressed on a separate report. Exit interview conducted and report emailed to administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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