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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802463
Report Date: 11/22/2022
Date Signed: 11/30/2022 09:47:28 AM

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
09/09/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200909205732
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:
11/22/2022
UNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Tanya Kramer/Belen GutierrezTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Insufficient staffing
Staff are mismanaging clients' medications
INVESTIGATION FINDINGS:
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This is an amended report to include additional information and clarification for the allegation of "staff mismanaging clients' medications:" Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 10:27AM and met with Administrator Tanya Kramer. Entrance interview conducted.

During today’s visit, LPA conducted a medication audit at 11:00AM and toured the facility at 11:20AM with the Administrator. Previously, on 09/15/2020, LPA along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QA) Liz Aced-Arnett initiated a complaint investigation telephonically with Charlotte Acosta, the facility’s District Manager (DM). During the virtual visit, LPA conducted a telephone interview with the DM and requested pertinent documents. Then throughout the course of the investigation, LPA and QA interviewed multiple staff and clients over the telephone and LPA reviewed pertinent documents. The following was then determined: Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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 6
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
09/09/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200909205732

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:
11/22/2022
UNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Tanya Kramer/Belen GutierrezTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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9
Staff did not prevent an altercation between clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 10:27AM and met with Administrator Tanya Kramer. Entrance interview conducted.

During today’s visit, LPA conducted a medication audit at 11:00AM and toured the facility at 11:20AM with the Administrator. Previously, on 09/15/2020, LPA along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QA) Liz Aced-Arnett initiated a complaint investigation telephonically with Charlotte Acosta, the facility’s District Manager (DM). During the virtual visit, LPA conducted a telephone interview with the DM and requested pertinent documents. Then throughout the course of the investigation, LPA and QA interviewed multiple staff and clients over the telephone and LPA reviewed pertinent documents. The following was then determined:
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20200909205732
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: 11/22/2022
NARRATIVE
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The complainant alleged that staff did not prevent an altercation between clients. It was alleged that Client #1 (C1) and Client #2 (C2) had an altercation outside where C2 hit C1. Interviews were conducted with both clients as well as multiple staff. While C1 did indicate there had been an altercation, C1 could not communicate when and where specifically the incident had occurred, nor where the staff were at the time of the alleged incident. C2 denied there being an altercation between the two clients, and states they like C1 and have no problem with them. Staff interview revealed that staff have never seen C2 hit C1. Interview revealed that C2 does follow C1 around the facility, but is kind to C1 and typically C1 will try to instigate C2. However, to date no physical altercations have been witnessed. Staff were aware of C1's allegation and indicated C1 often makes unfounded allegations. Review of C1's relevant documents confirmed a history of allegations made against other clients and staff alike. 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 did not prevent an altercation between clients" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. No citations related to this allegation were issued. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20200909205732
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: 11/22/2022
NARRATIVE
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Regarding the allegation “insufficient staffing:”

It was alleged that the facility did not have enough staffing for Client #1 (C1)’s 1:1 staffing ratio. During the visit that took place on 11/09/2020 for an unrelated complaint investigation, there were 3 staff on the permanent side and 1 staff on the crisis side. However, there were 2 clients on the crisis side. QA indicated the crisis side requires 1:1 staffing at all times for clients present. Therefore, with only 1 staff on the crisis side, the facility had insufficient staffing on that day. Additionally, interview revealed that often the facility is understaffed. At times, staff reported there is only 1 staff on the permanent side and 1 staff present on the crisis side. Client interviews revealed that often C1 goes outside and the staff assigned to C1 remains inside. LPA confirmed during in person visits that based on the layout of the house, C1 could not have had direct 1:1 supervision when the staff is inside the kitchen and C1 is outside. The kitchen does not have a window or direct access to the outside portion of the facility. Therefore, based on interview and observation, the allegation “insufficient staffing” is deemed SUBSTANTIATED at this time. A citation was issued on 11/09/2020 for the same allegation, therefore no citation will be issued for today’s complaint report.

Regarding the allegation: “Medication not administered as prescribed:”

During today’s visit, LPA along with Facility Administrator conducted a medication audit for one client, Client #2 (C2). C2’s medications reviewed were in compliance with regulation. However, previously, in September 2020, LPA and QA had received Medication Administration Record for Client #1 (C1) and Client #3 (C3). MAR dated 07/17/2020 – 08/13/2020 for C3 indicated C3’s Docusate Sodium, which is ordered “take one capsule twice daily” was marked as not available for the 8pm dose on 08/03/2020, both 8am and 8pm doses on 08/04/2020, and the 8am dose for 08/05/2020. Again on 08/10/2020 both doses are marked as not available, as well as the am dose on 08/11/2020. Review of C3’s MAR for the time period 08/14/2020 – 09/10/2020, for the 8pm dose on 08/24/2020, the medication was marked 5 – not available and there is a note indicating “insurance denied.” C3’s Docusate 100MG Caps was marked 5 – not available for the remainder of the dates covered on the MAR. C3’s Quetiapine 400MG tab is marked 7 – other for the 8pm dose on 08/28/2020, however there is no note indicating any additional details. MAR reviewed for 09/11/2020 – 10/08/2020 indicated C3’s Docusate 100MG Caps was not available until the 8pm dose on 09/18/2020. Additional pharmacy documentation provided indicated “product/service not covered” for C3’s Docusate 100MG Caps. Review of C1’s medications also included pharmacy documentation dated 09/18/2020 indicating “product/service not covered” for C1’s calcium/vitamin D 600MG-400unit tabs. Review Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20200909205732
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: 11/22/2022
NARRATIVE
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of C1’s MAR dated 08/14/2020 – 09/10/2020 and 09/11/2020 – 09/18/2020 indicated 5 – not available every day on the MAR for C1’s Calcium/Vitamin D. Interview revealed that Staff #1 (S1) had been purchasing both C1 and C2's medications that were not covered by insurance. Interview revealed the medications were available for purchase through the pharmacy without insurance coverage, and had been purchased by the facility while S1 was working at the facility. After S1 no longer was able to purchase the medications, the facility did not take additional steps to ensure C1 and C2 had the medications available, such as contacting the clients' families or obtaining a different prescription. Email provided by District Manager confirmed that C1 and C3 have been prescribed medications the insurance is not covering and therefore the facility has not been providing these medications as prescribed. Therefore, based on interview and record review, the allegation that “medication is not administered as prescribed 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. Lead staff was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted with facility Lead Staff Belen Gutierrez. A copy of the report was provided to facility Administrator via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20200909205732
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: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2022
Section Cited
CCR
80075(b)
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80075 Health-Related Services (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Lead staff agreed to conduct a vendorized medication training for all staff and send proof of completion, including name of trainer, date and duration of training, topic covered, roster of attendees to CCL by POC due date.
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Based on interview and record review, medications for C1 (Calcium/Vitamin D) and C3 (Docusate) were unable to be administered due to insurance not covering them and not having the medications present in the facility, which poses a potential health 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6