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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802463
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:08:22 AM

Document Has Been Signed on 09/27/2023 11:08 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 HOWEFACILITY NUMBER:
565802463
ADMINISTRATOR:DANSHELLE DAYFACILITY TYPE:
735
ADDRESS:3851 HOWE RDTELEPHONE:
(805) 398-5096
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 6CENSUS: 5DATE:
09/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Danshelle DayTIME COMPLETED:
11:07 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit regarding an incident which took place on 9/18/2023. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA and QAS met with administrator Danshelle Day and explained the reason for the visit.

The incident report stated that staff had moved the TV console in front of one of the doors on the crisis side of the facility. At 9:33 a.m. LPA and QAS inspected the crisis side and attempted to move the console but couldn't; it was very heavy. Staff 1 (S1) said client 1 (C1) is strong enough to move the console and does so when feeling fearful. S1 said they let C1 move the furniture around and then when C1 goes to sleep they move the furniture back in place. Staff do not move the furniture in front of the doors. There are three doors to exit the crisis side of the home. QAS asked staff to make sure they note when C1 moves the furniture and blocks the door.

The incident report also stated medication wasn't being given as prescribed for C1. LPA reviewed the medication administration records (MAR) and medication bubble packs at 10:30 a.m. Medications appear to be given as prescribed and when C1 refuses medications staff notes the refusals on the back of the MAR and the administrator submits an incident report to CCL and TCRC. LPA obtained copies of records at 10:50 a.m. The administrator has been attempting to reach out to the prescribing physician since June of 2023 to get an appointment for C1 but the physician's office is not responding. The physician continues to refill medications as originally prescribed but is not responding to questions regarding dosages. The administrator is going to continue to attempt to find a new physician.

No deficiencies were observed. Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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