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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802463
Report Date: 09/27/2022
Date Signed: 09/27/2022 02:41:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2020 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20200805170334
FACILITY NAME:PEOPLE'S CARE HOWEFACILITY NUMBER:
565802463
ADMINISTRATOR:SHAWN BAILEYFACILITY TYPE:
735
ADDRESS:3851 HOWE RDTELEPHONE:
(805) 398-5096
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY:6CENSUS: 5DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maria DrummondTIME COMPLETED:
02:46 PM
ALLEGATION(S):
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Staff did not provide one on one supervision to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek, along with Tri-Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett conducted a subsequent complaint inspection with the purpose of delivering findings for the allegation listed above. LPA arrived at the facility at 12:30PM and met with house lead Belen Gutierrez. House lead indicated acting Administrator was on her way. Acting Administrator Maria Drummond arrived at 01:42PM. Entrance interview conducted.

During today’s visit, LPA and QA interviewed staff and received copies of pertinent documents. Previously, on 08/12/2020, LPA Dulek and Tri-Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett conducted a telephone interview with the Administrator Shawn Bailey at 1:53 PM. The LPA also requested copies of pertinent documents. Then, on various dates throughout the course of the investigation, LPA and QA Liz Aced-Arnett conducted telephone interviews with staff members and clients. LPA also
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20200805170334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2022
NARRATIVE
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reviewed pertinent documents. The following was then determined:

Regarding the allegation that “staff did not provide one on one supervision to resident,” record review revealed that Client 1 (C1) requires 1:1 supervision at all times. During the time of the allegation, staff schedule did show that there was a 1:1 staff assigned to C1. Interview revealed that there was an incident involving Client #2 (C2) and during the incident, C1’s 1:1 staff went to assist with C2. Staff and Administrator stated that C1 was left outside unsupervised during the incident. Prior to the incident, C1 had also been unsupervised while C1’s 1:1 staff was inside cooking and C1 was outside smoking. During today’s visit, when LPA and QA arrived, C1 was observed to be outside with no 1:1 staff within line of sight. LPA and QA observed a swing outside in the shade where C1 chooses to spend time outside is not near a window, nor is it visible from the interior of the facility. Based on record review and interview, the allegation that “staff did not provide one on one supervision to resident” is deemed SUBSTANTIATED at this time.

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. Exit interview was conducted with Acting Administrator Maria Drummond. 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: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200805170334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2022
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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LPA confirmed sufficient staffing for the remainder of the week. Acting Administrator agreed to move the bench to an alternate location. Acting Administrator will retrain staff on line of sight, document the retraining and send a copy of the training
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Based on interviews and observation, during an incident involving another client, staff left C1 unsupervised to assist with the incident, which poses an immediate health and safety risk to clients in care.
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to CCL by 10/07/2022.
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2020 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20200805170334

FACILITY NAME:PEOPLE'S CARE HOWEFACILITY NUMBER:
565802463
ADMINISTRATOR:SHAWN BAILEYFACILITY TYPE:
735
ADDRESS:3851 HOWE RDTELEPHONE:
(805) 398-5096
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY:6CENSUS: 5DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Maria DrummondTIME COMPLETED:
02:46 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not following resident’s behavioral plan
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek, along with Tri-Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett conducted a subsequent complaint inspection with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 12:30PM and met with house lead Belen Gutierrez. House lead indicated acting Administrator was on her way. Acting Administrator Maria Drummond arrived at 01:42PM. Entrance interview conducted.

During today’s visit, LPA and QA interviewed staff and received copies of pertinent documents. Previously, on 08/12/2020, LPA Dulek and Tri-Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett conducted a telephone interview with the Administrator Shawn Bailey at 1:53 PM. The LPA also requested copies of pertinent documents. Then, on various dates throughout the course of the investigation, LPA and QA Liz Aced-Arnett conducted telephone interviews with staff members and clients. LPA also
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200805170334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2022
NARRATIVE
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The following was then determined:

The allegation “staff not following resident’s behavioral plan” references Client #1 (C1) having time on an electronic tablet. During the course of the investigation, LPA Dulek reviewed C1’s behavior assessment and support plan. There is no mention of using a tablet, nor are there written parameters for tablet use. Interview revealed that C1’s conservator had supplied the tablet to C1 for use at the facility. Staff allow supervised tablet use, per C1’s request. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation that “staff not following resident’s behavioral plan” is deemed UNSUBSTANTIATED at this time.

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: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5