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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802463
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:47:00 PM

Document Has Been Signed on 08/02/2022 04:47 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:CARLOS MARCIAFACILITY TYPE:
735
ADDRESS:3851 HOWE RDTELEPHONE:
(805) 398-5096
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY: 6CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Belen GutierrezTIME COMPLETED:
03:22 PM
NARRATIVE
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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 07/29/2022 at 05:48PM. LPA arrived at the facility at 11:55AM and initially met with facility staff Tiana Viveros. Staff indicated Administrator Carlos Marcia was unavailable for today's visit; LPA spoke with Administrator at 01:17PM and confirmed House Lead is authorized to sign reports for the facility. House Lead Belen Gutierrez arrived at the facility at 01:30PM. Entrance interview conducted.

The incident report was authored by Administrator Carlos Marcia indicated that Client #1 (C1) had eloped from the facility around 2:07PM on 07/28/2022. Incident report further indicated that around 2:00PM shift change, incoming staff had observed C1 walking away from the facility and towards the traffic light about to cross the street towards the gas station. The incident report narrative indicates incoming staff remained with C1 until another staff came to pick C1 up and return C1 to the facility.

During today's visit, LPA, along with facility staff Tiana Viveros, toured the facility grounds inside and outside at 11:58AM. No immediate health and safety hazards were identified during today's visit. Additionally, LPA conducted staff interviews at 12:32PM, 01:47PM, 02:46PM, and 02:49PM, as well as client interviews at 12:45PM and 01:02PM. LPA reviewed and gathered copies of pertinent documents related to the incident. Interviews revealed that C1 was outside during shift change. During shift change outgoing staff sit down, make notes and share updates with incoming staff. Outgoing staff remained inside during shift change, while C1 was outside. Staff #1 (S1) and Staff #2 (S2) initially saw C1 outside walking on the street towards the highway. S1, and S2 came to the facility and reported in person they saw C1. Interview revealed that staff did not remain with C1 during the elopement. Staff #3 (S3) was present at the facility and once relieved, S3 left the facility to pick up C1. When S3 observed C1, C1 was
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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 HOWE
FACILITY NUMBER: 565802463
VISIT DATE: 08/02/2022
NARRATIVE
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crossing the highway back and returning towards the facility. Record review indicated C1 has a documented elopement behavior and staff are aware of C1's behavior needs.

During today's visit, LPA observed the fence C1 stated they climbed over, and the path C1 reportedly took during the elopement. LPA noted the gas station is located across the highway and is 1/2 mile from the facility location. Additionally, although there is a stoplight at the highway, where C1 reportedly crossed, there is no pedestrian crossing. There is no crosswalk and posted signs indicate no pedestrians.

The following deficiency was 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. Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2022 04:47 PM - It Cannot Be Edited


Created By: Kelly Dulek On 08/02/2022 at 02:34 PM
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 HOWE
FACILITY NUMBER: 565802463

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2022
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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House Lead agreed to provide CCL with an updated copy of the facility elopement procedure as well as conduct a vendorized training on supervision and elopement and provide proof of training to include name of trainer, date/time conducted, topics covered, and attendees by POC due date.
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Based on interview and record review, the facility did not comply with the above cited section, as C1 eloped from the facility, which poses an immediate safety risk to clients 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
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