summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility to complete the case management inspection started on 2/2/2024 regarding an incident report submitted to CCL dated 12/28/2023, which detailed medication errors, and met with Facility Manager Quinisha Silva. The incident report stated that Client C1 was given incorrect doses of one of their medications on 12/23/2023-12/27/2023 at 7am, 11am, 3pm, and 7pm; the 1MG dose was given instead of 2MG dose. The facility identified this was due to the facility using old medication that was set to be destroyed while awaiting a medication refill. This medication that was utilized was the incorrect dose. Refills were not obtained in advance as they should have been, and staff should have noticed this error immediately if they looked closely and completed the count protocol per their training. "It was later discovered that the medication that was in the bottle was in fact only 1MG tablets of [the medication]. It is unclear as to how only 1MG tablets were in a bottle of 2MG [medication]." To prevent delays in getting refills, the facility will be switching over to a different pharmacy which can better serve their needs. Facility trained staff on medication: looking at the pills and making sure they are the right dosage, right size, and that they are out of the right container before administering, and there have been weekly internal medication audits since then. On this date LVN Alex Pulido was present conducting the medication audit during LPA's inspection. LPA obtained a copy of the training record for the medication training related to this incident. On this date, the facility is being cited for violations of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80075(l) Health Related Services, and Section 80078(a) Responsibility for Providing Care and Supervision. LPA amended the citation issued on 2/7/2024 for 80075(k)(6), to include the 1MG medication being inside of a 2MG medication bottle. The POC for that citation has been modified as well. An exit interview was conducted with FM and a copy of this report, amended 809-D 2/7/2024, and appeal rights were provided to them.


state: CA

facility_name: PEOPLE'S CARE PLEIDES

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess and Licensing Program Manager (LPM) Jodean Hall made an unannounced case management inspection at the facility for the purpose of addressing the deficiencies found at the facility on 5/31/2024 and for the case management opened that day. Based on the incident report submitted to CCL by the facility and statements from the Administrator, LPA confirmed the facility did administer an extra dose of C1's M1 (refer to Confidential Names List dated 5/31/2024) from 5/7/2024 - 5/21/2024, 15 additional doses, due to the facility not destroying the old medication as required, and not replacing the MAR as required. Additionally, revealed on 5/31/2024 during LPA and LVN's medication review for C1, LPA found the following: 1. The old MAR for the overdosed M1 was missing and believed by LVN and District Manager to have been destroyed, so LPA could not review it. 2. On M2's MAR from 5/17/2024 - 5/21/2024, there were X's on the current MAR, and LVN stated there was another MAR where it was filled out for 5/17/2024 - 5/21/2024, however that MAR was unable to be located. 3. For M2 the fill date was incorrect as it stated it was filled on 12/19/2023, when it had actually been filled on 5/8/2024. 4. M3 was started on 5/23/2024, the MAR showed this as well, given through today, there are 27 pills that have been taken. There are 39 left, which leaves an excess of one dose. 5. M1 for 5/22/2024 showed there was the same problem, one extra dose. The MAR showed 9 doses have been taken, and there are 13 left. However, there should have only been 21 total and based on counts, there is one extra dose. 6. For M4, there are 13 daily doses left, the counts should add up to 28, which is what was filled. However, there were 3 different MARs for the same med, M4, with different numbers, different dates, which was indecipherable. It was filled at 42 pills, it started 5/23/2024 in the PM. 16 pills were marked as taken, 27 were left, totalling 43. Based on the MAR and physical medication, there is one extra pill (a half of a daily dose), which cannot be explained. 7. For M7, the CSMDR stated 80 pills of M7 was destroyed on 5/23/2024. However, M7 is still present and being administered. LVN could not explain what happened. There are M7 left, so 58 were supposedly given, however the MAR only stated 38 were given. The two medication errors for M3 and M1 with the counts being off by one, the LVN was to have called the pharmacy to obtain the correct records for this, however on this date during this inspection, that had not yet been completed. Administrator informed LPA that LVN is working on it right now. LVN called Admin and informed LPA that for both M1 and M3, the MAR should have started on 5/23/2024, so staff started it a day earlier. The facility had to switch the medication packs, so the new tray came on the 23rd. The MARs were incorrect, instead of starting the MAR on the 23rd, they continued on the old MAR. On 5/31/2024, LPA did not have access to the facility safe, in which client funds and financial records are kept. LPA was informed that since 5/24/2024, the facility has not had access. Administrator informed LPA that they have been working to get it open and she has been in contact with HR. Administrator forwarded LPA the email chain discussing this. On this date, there was still no access to the facility safe. LPA and LPM spoke with District Manager John O'Brien on this date, who called a person to come open it today. On this date, the facility is being cited for repeated violations of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80075(l) Health Related Services, and Section 80078(a) Responsibility for Providing Care and Supervision, and Section 84070(b)(13) (third repeat citation in one year) Children's Records, and a repeat civil penalty in the amount of $250 for each will be assessed. For each day the deficiencies go uncorrected, an additional $100 per citation, per day, will be assessed. On this date, LPM requested copies of the 15-Minute Checks for C1's medication for May. LPM was informed that most of them were shredded, however four of them for May 2024 were left. There were no medication names on any of them to determine which checks were done for which medications, so the documentation was not useful. The facility is also being cited for violations of the California Code of Regulations, Title 22, Division 6, Chapter 5, Inspection Authority of the Department of Licensing Agency, Sections 84044(b), and 80044(c). An exit interview was conducted with DM and a copy of this report and appeal rights were provided to him.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Diane McGill


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Connie Goldie made an unannounced case management inspection at the facility's administrative office located at N Freeway Blvd Suite Sacramento, CA 95834 and met with Program Director John O'Brien, who assisted with the inspection. The purpose of this Case Management is to address facility staff not providing factual information to employees of the Department. 1. On 5/31/ LPA interviewed Administrator Diane McGill for the complaint dated 5/29/2024. During the interview LPA asked Administrator if she offered to cash a client's check(s) through her personal bank account and she denied it. However, during an interview with Program Director, he admitted that Administrator did offer to do this, as did the Reporting Party of the complaint. 2. On 7/29/ LPA interviewed a staff (S1) for the complaint dated 7/23/2024 regarding staff smoking in the presence of client(s). During the interview, the staff denied to LPA that staff smoked in front of the client, and did not admit that it was true until presented with photographic evidence. 3. On 8/13/ LPA Connie Goldie was present in the facility with the Department's Investigations Branch Investigator Austin Blatnik during an interview in which S1 denied that he was pulled over by police in the People's Care company vehicle. It was not until the investigator communicated with S1 that there was police report about it, that S1 admitted it was true. In addition, for complaint dated 7/23/2024, LPA found that Administrator Diane McGill did not inform the Program Director that it was true that staff had been found smoking in front of a client, and on facility property when LPA presented Administrator with photographic evidence of such on 7/29/2024. On 8/13/2024 when LPA delivered those findings, Program Director informed LPA that Administrator did not inform him. As a result, the problem had not been addressed immediately as Administrator informed LPA it would be on 7/29/2024. On this date the facility is being cited for violations of the California Code of Regulations, Title 22, Division 6, Chapter 5, Section 84064(f)(4), and the California Health and Safety Code, Section 1558(a)(2) on the attached D-Page. An exit interview was conducted with PD and a copy of this report, confidential names list, and appeal rights were provided to him.

met_with: John O'Brien


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess and Connie Goldie made an unannounced case management inspection at the facility's administrative office located at N Freeway Blvd Suite Sacramento, CA 95834 and met with Program Director John O'Brien, who assisted with the inspection. CCL received two incident reports dated 8/23/2024 and 9/15/2024 which detailed medication errors made with client C1's medication. 8/23/2024: QA confirmed that C1 had a missed dose of M1 (see Confidential Names List dated 10/15/2024). QA reviewed the medication packs and found the M1 bubble packs started on different days, and staff informed QA that it was because there was a single pill left over from the pharmacy pill bottle. QA followed up with facility nurse and staff present on that day. It is unclear whether it was an AM or PM dose which was missed. Corrective action will be given to the staff and retraining will occur. Staff will send pictures of every medication pass to QA before it is taken by the resident. 9/15/2024: During a medication audit conducted on 9/16/2024 by the facility nurse, it was discovered that one dose of M1. QA staff followed up with staff via conversation and text messaged pictures from staff, and in speaking with the staff on 9/17/2024 it was confirmed that the dose was not administered. Corrective action will be given to the staff and a retraining will occur. Staff will send pictures of every medication pass to QA staff to confirm the correct quantity is being administered. The facility was previously cited for medication dosing errors on 2/9/2024 and 6/3/2024. In a corrective action plan submitted to CCL by People's Care on 6/3/2024 for multiple medications violations cited on that date (See 809 dated 6/3/2024), part of the submitted plan stated: "Implementation of the "Red Apron" Protocol in conjunction with photos of each and every medication pass will be the new standard at the Pleides Group Home for the foreseeable future. The "Red Apron" Protocol will be a permanent addition to the Pleides medication protocol. This new level of focused attention to detail is to ensure that the person wearing the red apron is not to be engaged by staff or the Residents while administering medications. Distractions is often the cause for errors, and we want to set our staff up for success and do everything within our power to keep our Residents safe. The photos of the medication passes will be on-going and reevaluated at a later date." Based on the two further medication errors occurring, this plan was either not implemented, is not being followed up on as required, or is ineffective. On this date, the facility is being cited for a repeat violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Section 80078(a) Responsibility for Providing Care and Supervision (third repeat citation in one year), and assessed a repeat citation civil penalty in the amount of $250. For each day the deficiency goes uncorrected, an additional $100 per day will be assessed. An exit interview was conducted with PD and a copy of this report, Confidential Names List, and appeal rights were provided to him.

Deficiencies:
95834: QA confirmed that C1 had a missed dose of M1 (see Confidential Names List dated 10/15/2024). QA reviewed the medication packs and found the M1 bubble packs started on different days, and staff informed QA that it was because there was a single pill left over from the pharmacy pill bottle. QA followed up with facility nurse and staff present on that day. It is unclear whether it was an AM or PM dose which was missed. Corrective action will be given to the staff and retraining will occur. Staff will send pictures of every medication pass to QA before it is taken by the resident.

9/15/2024: During a medication audit conducted on 9/16/2024 by the facility nurse, it was discovered that one dose of M1. QA staff followed up with staff via conversation and text messaged pictures from staff, and in speaking with the staff on 9/17/2024 it was confirmed that the dose was not administered. Corrective action will be given to the staff and a retraining will occur. Staff will send pictures of every medication pass to QA staff to confirm the correct quantity is being administered.


facility_name: PEOPLE'S CARE RESMAR

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews stated S1 used profanity and stated it was a reaction to C1 taking S1's food however S1 is aware profanity is not tolerated at the facility. Confidential interviews stated S1 was given a corrective action, and re-training for professionalism in the workplace. Based on confidential interviews, the preponderance of evidence standard has been met and the allegation that staff #1 (S1) used profanity towards client #1 (C1) is substantiated at this time. This poses a potential health, safety, or personal rights risk to residents in care. The facility is being cited for violation of California Code of Regulations, Title 22, Division six, Section 84072(d)(10): Personal Rights. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Program Administrator Jose Armando Guzman, along with the LIC 811. Original signed reports will be placed in facility file.

Investigation Findings:
13On 05/14/2021 at 9:00 a.m.,due to COVID 19, LPA Licensing Program Analyst (LPA) Marisol Lopez met with Program Administrator Jose Armando Guzman of People's Care Resmar via tele-inspection to discuss the investigative findings for the allegations noted above. On 10/21/2020 at 12:30 p.m., due to COVID 19, LPA met with Program Administrator Zela Negrete via tele-inspection to initiate complaint investigation and conducted a safety check; no safety hazards observed. During the investigation, LPA Lopez conducted confidential interviews with five staff, one administrator, and reviewed incident report. LPA attempted interviews with three of three clients, however, they were unable to understand or answer questions. On 10/14/2020, the Department received an allegation that staff #1 (S1) used profanity towards client #1 (C1). It was reported that C1 reached and grab some food that was not C1's and shoved it into C1's mouth while S1 used profanity towards C1. It was also reported there was no physical contact and Staff does not think C1 understood what S1 was saying as C1 has a very low cognitive level. It was also stated C1 has not expressed any concerns about staff before however, C1 is non-verbal and uses small gestures, limited sign language, and an iPad with pictures to communicate. (See continuation form LIC9099-C dated 05/14/2021) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: 374603931

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

report_type: Complaint Investigation

met_with: Jose Armando Guzman

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews denied having heard of S1 using inappropriate forms of discipline however, other statements stated the allegation occurred but did not have further details and no witnesses of the incident. Confidential interviews were attempted with three of three clients, however clients were not able to be interviewed due to inability to comprehend or answer questions. Based on confidential interviews, the allegation that staff #1(S1) used an inappropriate form of discipline may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted and a copy of this signed report was emailed to Program Representative Otilli Abuka.

Investigation Findings:
13On June 01, 2022, at 1:00 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Otilli Abuka of People's Care Resmar to discuss the investigative findings for the allegation noted above. On August 25, 2021, at 2:00 p.m., Licensing Program Analyst (LPA) Marisol Lopez met with Program Representative Otilli Abuka to conduct an unannounced initial complaint investigation. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA Lopez conducted confidential interviews with six staff (S1-S6), one program representative, attempted interviews with three of three clients (C1-C3), and reviewed incident reports. On 08/20/2021, the Department received allegations that staff #1(S1) handled client #1(C1) in a rough manner. It was reported C1 grabbed S1's hair and S1 poured a cup of water on C1 to get C1 to let go of S1's hair. Confidential interviews contradicted the information stating there have not been any incidents involving S1 pouring water on C1. (see continuation form LIC 9099-C dated 06/01/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 06/01/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Otilli Abuka

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews contradicted the information stating that staff have never provided any non-medically approved substances to any client and that the program administrator is available to speak to the case workers daily. Confidential interviews denied the allegations occurred however, other information provided alleged the incidents occurred and no other witnesses were available. Based on confidential interviews, the allegations that facility staff gave client#1 (C1) a non-medically approved substance and facility staff is not communicating with case managers while in care may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was emailed to Facility Administrator Levy Middlebrooks.

Investigation Findings:
13On August 12, 2022, at 12:10 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Facility Administrator Levy Middlebrooks of People's Care Resmar to discuss the investigative findings for the allegations noted above. On November 09, 2021, at 11:45 a.m., Licensing Program Analyst (LPA) Marisol Lopez met with Program Manager Otilli Abuka to conduct an unannounced initial complaint investigation. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with one case worker, one program administrator, one program manager, four staff (S1-S4), one of three clients (C1-C3) interviews was attempted however C1 refused and clients (C2-C3) were unable to answer LPA's questions. On November 08, 2021, the Department received allegations that facility staff gave client #1 (C1) a non-medically approved substance and facility staff is not communicating with case managers. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 08/12/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Levy Middlebrooks


raw_content:
Narrative:
a resident, and staff spoke inappropriately to resident. It was reported that staff picked up the resident from school, kissed them on the cheek, and referred to themself as the resident's boyfriend. Confidential interviews reviewed S1 was assigned to C1 as their one-on-one staff and did not refer to themself as their boyfriend or kiss C1 on the cheek while at the facility. Confidential interviews revealed S1 was not left alone with C1 and S1 displayed appropriate boundaries with C1. While other interviews revealed that S1 referred to C1 as beautiful in Spanish and could be their boyfriend. Based on confidential interviews and records reviewed that staff inappropriately touched resident and staff spoke inappropriately to resident, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was discussed with Levy Middlesworth, Facility Administrator. Due to printer malfunction, a copy of this report, along with the LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file

Investigation Findings:
13On September 2, 2022, at 1:25 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Levy Middlesworth, Facility Administrator, to discuss the investigative finding for the allegationslisted above. LPA Marisol Lopez conducted an inspection of the facility on 10/12/2021 at 2:00 pm and no deficiencies were observed. LPA Linley conducted an inspection of the facility on 08/12/2022 at 2:30 pm. No deficiencies were observed. During the investigation, LPA interviewed seven out of nine staff (S1, S2, S4-8), C1's teacher (ETA), attempted interview with one of one client (C1), and was unable to interview due to being unable to answer LPA's questions, and was unable to interview C1's Behavior Analyst (BA), a representative from the Behavioral Health organization (REP), and an official from the school district (GSD), due to multiple attempts to contact them. LPA also reviewed the following documents: C1's Individual Program Plan (IPP), C1's annual plan, and S1's employee file. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 09/01/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


raw_content:
Narrative:
Confidential interviews reviewed conflicting statements, some interviews revealed that C1's diaper was checked before they got on the bus to go to school, some interviews indicated that the facility was notified by the school about the soiled diapers, while other interviews revealed that C1 drank liquids before getting on the bus and could have soiled their diaper while riding the bus to school. Based on confidential interviews and records reviewed the staff sends C1 to school with soiled diapers which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was discussed with Levy Middllebrooks, Facility Administrator. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file. reside in the facility. Confidential interviews revealed it is unknown if an age exception was submitted to CCL for C1 to remain in the facility past their 18th birthday. Records reviewed indicated that C1 turned 18 years old prior to the allegation and that the facility did not have an age exception for C1 to reside at the facility after their 18th birthday. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met regarding the allegation that the facility is operating beyond the license conditions and limitations. This posed a potential Health, Safety, or Personal Rights risk to C1 in care, the facility will be cited for violating Title Regulations, Division 6, Chapter 1, Article 3 80024(a)(2) Waivers and Exceptions.

Investigation Findings:
13On September 2, 2022, at 1:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Levy Middllebrooks, Facility Administrator, to discuss the investigative finding for the allegation listed above. LPA Carol Anderson conducted an inspection of the facility on 09/09/2021 at 3:10 pm and no deficiencies were observed. LPA Linley conducted an inspection of the facility on 08/12/2022 at 2:30 pm. No deficiencies were observed. During the investigation, LPA interviewed seven out of nine staff (S1, S2, S4-8), Regional Center Service Coordinator (SC), attempted interview with one of one client (C1), and was unable to interview due to being unable to answer LPA's questions, and was unable to interview C1's teacher (ETA), despite multiple attempts to contact them. LPA also reviewed the following documents: C1's Individual Program Plan (IPP), C1's annual plan, and client roster. On August 1, 2021, Community Care Licensing received an allegation that staff sends C1 to school with soiled diapers. It was reported that C1 was sent to school with soiled diapers and soiled clothing. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 09/02/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion: SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


raw_content:
Narrative:
supervise resident. It was reported that C1 exited the facility, unsupervised, took off their clothes, and walked into the street. It was reported that staff did not go outside and look for C1. Confidential interviews reviewed conflicting statements, some interviews revealed that C1 had a one-on-one behavioral associate that followed them each time they left the facility, while other interviews revealed staff followed C1 when C1 eloped from the facility. Confidential interviews revealed when C1 walked out of the facility C1 was given space and staff monitored C1 from a distance until they returned to the facility in order to avoid escalating C1 to run further away from staff. Based on confidential interviews and records reviewed that staff did not properly supervise C1, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Christy Escobar, DSP. Due to printer malfunction, a copy of this report, LIC 811, and appeals will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On September 16, 2022, at 3:00 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Christy Escobar, DSP, to discuss the investigative finding for the allegation listed above. LPA Carol Anderson conducted an inspection of the facility on 09/29/2021 at 3:15 pm and no deficiencies were observed. LPA Linley conducted an inspection of the facility on 08/12/2022 at 2:30 pm. No deficiencies were observed. During the investigation, LPA interviewed seven out of eight staff (S1, S2, S4-8), and attempted interview with one of one client (C1), who was unable to be interviewed due to not being able to answer LPA's questions, C1's behavioral consultant (BC), and School District Official (GSD) were not interviewed, LPA made multiple attempts to contact them with no response. LPA also reviewed the following documents: C1's Individual Program Plan (IPP), C1's annual plan, Special Incident Report for C1 dated 06/29/2021, staff schedule, and client roster. On August 1, 2021, Community Care Licensing received an allegation that staff did not properly UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 09/15/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Christy Escobar, DSP


raw_content:
Narrative:
participate in school extracurricular activities, clients were not provided with adequate clothing, and facility staff did not respond to clients school request for information. It was reported that the school contacted the facility for the clients to attend a swimming field trip over the Summer, the clients did not attend, and communication was not given why they did not attend the field trip. It was reported that the school contacted the facility multiple times to obtain a medication authorization form for clients to have medication stored and administered while at school. It was reported that C1 did not have clothes that fit and were too small. Confidential interviews revealed conflicting statements. Confidential interviews revealed permission slips were sent to the facility on three dates and communication was not provided for C1 and C2 being able to attend a swimming field trip during Summer School, therefore, C1 and C2 did not attend the swimming field trip. Conflicting interviews revealed the permission slips were signed off; however, a staff name could not be verified, and it was revealed swim diapers were not found in C1 and C2's sizes, however, confidential interviews revealed other stores were not checked to see if swim diapers were in stock in C1 and C2's size. Regarding the allegation that facility staff does not respond to school request for information, confidential interviews revealed that the school requested authorization for C1 and C2's medication to be changed to 12:00pm, be stored, and administered at the school. Confidential interviews revealed emails and phone calls were made to the facility and the facility did not obtain the medication authorization form until school started in August 2022. Conflicting interviews revealed the school desired the medication to be changed and the physician's name and the number was provided to the school to communicate the medication changes and obtain authorization. Conflicting interviews and records revealed the school found C2's medication authorization form was previously signed and the facility obtained the medication authorization form for C1 that was signed by the physician two weeks after school started and the form was given to the school. Lastly, for the allegations that clients are not provided with adequate clothing, there is conflicting information. Confidential interviews revealed that clients receive monthly funds for clothing and incidentals. Confidential interviews reveal that staff completed a monthly inventory and purchased clothing and shoes, as needed for the clients. Conflicting interviews revealed observations that C1 and C2 appear to wear clothing that is too small for them. Records reviewed indicated C1 and C2 had clothing purchased in August 2022. Based on confidential interviews and records reviewed the staff did not allow C1 and C2 to participate in school extracurricular activities, C1 and C2 are not provided with adequate clothing, and facility staff do not respond to school requests for information, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Levy Middlebrooks. A copy of this report will be placed in the facility file.

Investigation Findings:
13On October 14, 2022, at 8:30 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Levy Middllebrooks, Facility Administrator, to discuss the investigative findings for the allegations listed above. LPA Linley conducted an inspection of the facility on 08/25/2022 at 2:20 pm. No deficiencies were observed. During the investigation, LPA interviewed two staff (S1, S2), and attempted interviews with two clients (C1, C2), who were unable to be interviewed due to not being able to answer LPA's questions, and the Regional Center representative (RC) was interviewed. LPA also reviewed the following documents: Emails between School Nurse and Facility Administrator, August Clothing Inventory and Shopping Receipts for C1 and C2, Authorization for Medication Administration for School for C1 and C2, Medication Administration Records for June and July 2022 for C1 and C2, and Nutritional Assessment for C1. On August 25, 2022, Community Care Licensing received allegations that staff did not allow clients to UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 10/13/2022

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Based on confidential interviews, the allegation that staff physically assaulted C1 while in care may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report along with appeal rights was provided to Otili Abuka, Admin .

Investigation Findings:
13On November 8, 2023, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Shelly Ann Smith, House Lead & Otili Abuka, Admin to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on August 14, 2023, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed two staff (S1- S2), one client (C1) and obtained C1's Individual Program Plan (IPP), and SIR. LPA attempted to interview C2 and C3, however both clients are non verbal. On August 10, 2023, the department received allegations that staff physically assaulted youth while in care. Confidential interviews indicated conflicting statements whether staff physically assaulted youth while in care and there where were no witnesses of the events. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 11/08/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
Based on confidential interviews, the allegation that staff hit C1 and staff made inappropriate comments towards C1 may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report along with appeal rights was provided to Otili Abuka, Admin .

Investigation Findings:
13On November 8, 2023, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Shelly Ann Smith, House Lead & Otili Abuka, Admin to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on July 25, 2023, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S1, S3, S4), one client (C1) and obtained C1's Individual Program Plan (IPP), SIR, and staff schedule with contact information. LPA attempted to interview S2, however after numerous attempts LPA was unsuccessful. LPA attempted to interview C2 and C3, however both clients are non verbal. On July 28, 2023, the department received allegations that staff hit minor, and staff made inappropriate comments towards minor. Confidential interviews indicated conflicting statements whether staff hit minor, staff made inappropriate comments towards minor and there were no witnesses to the events. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 11/08/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Confidential interviews indicated after 45 minutes S1 went to the facility and returned with a bottle of water. S1 offered C1 the bottled water, poured water on C1's face causing C1 to escalate, attacking S1 and bit S1's leg. Based on confidential interviews and document review, the allegation that S1 poured water on C1 while in care are SUBSTANTIATED because the preponderance of evidence has been met. This poses an immediate an Health, Safety, or Personal Rights risk to children in care, the facility will be cited for violating Title 22, Division 6, Chapter 5, Article 06. Continuing Requirements Personal Rights(d)(10). An exit interview was conducted, and plan of corrections was developed with Shelly Ann Smith, House Lead & Otili Abuka, Admin. A copy of this report and appeal rights were provided to Otili Abuka, Admin.

Investigation Findings:
13On November 8, 2023, at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection. The purpose of the inspection is to deliver the findings for the above allegation. LPA Jauregui met with Shelly Ann Smith, House Lead & Otili Abuka, Admin. LPA Jauregui conducted an inspection of the facility on August 30, 2023, and no deficiencies were noted. During the investigation, LPA Jauregui conducted two staff (S1, S2) interviews, one witness interview and obtained incident report. LPA was unable to interview C1 due to C1 being non verbal. On August 24, Community Care Licensing (CCL) received the allegation that staff poured water on a minor while in care. Confidential interviews indicated C1 did not want to get off the school bus and tucked themselves in under the seat. Confidential interviews indicated snacks and a phone call to C1's aunt was offered and C1 refused. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 11/08/2023

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0


raw_content:
Narrative:
The confidential interview reported that S1 and S2 needed to get C1 inside the facility, so S1 and S2 attempted to do a CPI hold, however, it was unsuccessful due to C1 dropping their weight to the ground. A confidential interview stated that S2 attempted to grab on to C1's arm for a hold, however, S1 grabbed and dragged C1 into the garage. A confidential interview maintained that staff kicked and stepped on C1's foot during the dragging. Based on confidential interviews, the preponderance of evidence standard has been met, therefore, the allegation that S1 dragged and kicked C1 in care is substantiated. The facility is being cited for violation of the Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements for Personal Rights, 80072(a)(1) (See LIC9099D). An exit interview was conducted, and plan of corrections was developed with Otili Obuka, Administrator. A copy of this report and appeal rights were provided to Otili Obuka, Administrator.

Investigation Findings:
13On July 2, 2024, at 2: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Obuka, Administrator to discuss the investigative findings for the above allegation. LPA Jauregui conducted an inspection of the facility on March 20, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S1-S3) and two clients (C1-C2). On March 15, 2024, the Department received the allegation that staff dragged and kicked minor in care. Confidential interviews reported that C1 was having a behavior outside the facility where C1 wanted to get on the school bus with the iPad, however, C1 is not allowed to do that. Confidential interviews added that C1 began screaming and running on the street, and neighbors who observed the incident expressed concerns due to the C1's yelling. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 07/02/2024

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Otili Obuka, Administrator


raw_content:
Narrative:
A confidential witness reported that S1 started to lose their patience and S1 began to raise their voice at C1 and pushing C1; therefore, S4 attempted to intervene, however S1 pushed S4 to the side and S1 pushed C1 back causing C1 to lose their balance and fall on a large purple bean bag which resulted C1 engaging in self-harm behaviors such as hitting their face, legs, and biting. It was further reported that C1 stood up and charged back at S1 and S1 grabbed C1 by the hair and yanked C1's head back. Confidential interviews indicated S1 placed C1 in a hold with C1's hands behind their back. Confidential interviews indicated S1 and S4 do not have the training nor the authorization to place clients on any type of hold. Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, therefore, the allegation that S1 handled C1 in care in a rough manner is substantiated. The facility is being cited for violation of the Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements for Personal Rights, 80072(a)(3) (See LIC9099D). An exit interview was conducted, and plan of corrections was developed with Otili Obuka, Administrator. A copy of this report and appeal rights were provided to Otili Obuka, Administrator. The confidential interview reported that it is unknown whether the injuries were caused by S1 or self-injurious behavior. Based on confidential interviews and record review, the allegations that C1 sustained unexplained injuries while in care due to lack of supervision, may have occurred, however, there was not a preponderance of evidence to support or deny the allegation. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Otili Obuka, Administrator.

Investigation Findings:
13On July 2, 2024, at 2: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Obuka, Administrator to discuss the investigative findings for the above allegation. LPA Jauregui conducted an inspection of the facility on December 19, 2023, and deficiencies were noted. During the investigation, LPA Jauregui interviewed four staff (S1-S4). LPA was unable to interview C1 due to C1 being non- verbal. On December 18, 2023, the Department received the allegation that staff handled minor in care in a rough manner. Confidential interviews indicated S1 and S4 came from another facility named Maximum to assist C1 due to C1 needing extra support. Confidential interviews reported that C1 wanted to go on a van ride, however, S1 and S4 did not have the approval to do so. The confidential interviews continued stating that C1 would grab S1's hand and guided S1 to the door, however, S1 was gentle and broke away from C1's grip. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 07/02/2024

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


raw_content:
Narrative:
Confidential interviews indicated that on 11/01/2023, S3 and S4 took C1 to Urgent Care, however, staff were advised to take C1 to the Emergency Room and S3 and S4 took C1 to the Emergency Room. It was reported that C1 was not seen at the hospital due to staffing issues and S3 and S4 were at the end of their scheduled shift and could not stay. Therefore, C1 was brought back to the facility. Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, therefore, the allegations that staff did not ensure that C1 received medical care and staff did not follow medical advice given for C1 are substantiated. The facility is being cited for violating Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements for Health-Related Services, 80075(a) (See LIC9099D). An exit interview was conducted, and plan of corrections was developed with Otili Obuka, Administrator. A copy of this report and appeal rights were provided to Otili Obuka, Administrator. During the investigation, confidential interviews reported that staff noticed the house tablet was missing and S1 asked C1 for the tablet which resulted in C1 being agitated and verbally aggressive towards S1 by throwing the tablet at S1. Confidential interviews received conflicting statements. Regarding the allegations staff did not follow reporting requirements and staff did not ensure that minor was available for their own medical appointment, it was specified that staff did not properly report concerns to medical providers. It was reported that C1 was not present for their telehealth appointment. Record review indicates on November 3, 2023, C1 was taken to the Emergency Room. Confidential interviews stated that a telehealth appointment was on the November 3, 2023. LPA received conflicting information. Based on confidential interviews and record review, the allegations that S1 made inappropriate comments to C1, S1 hit C1 with an object, staff did not follow reporting requirements, and staff did not ensure that minor was available for their own medical appointment, may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Otili Obuka, Administrator.

Investigation Findings:
13On July 2, 2024, at 2: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Obuka, Administrator to discuss the investigative finding for the above allegations. LPA Jauregui conducted an inspection of the facility on November 8, 2023, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S1, S2, S5), one client (C1), and obtained C1's face sheet, Special Incident Report dated 10/31/23, staff schedule week of 10/29/23-11/4/2023, staff contact information, school referral to a health evaluation for concussion symptoms dated 10/31/23 , and emergency room visit discharge paperwork dated 11/3/2023. On November 2, 2023, the Department received the allegations that staff did not ensure that minor received medical care and staff did not follow medical advice given for minor. Record review indicates on October 31, 2023, C1 was given a school referral to a health evaluation for concussion symptoms. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 07/02/2024

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


raw_content:
Narrative:
LPA was unable to receive additional information. Based on confidential interviews, the allegations that S1 made inappropriate comments to C1 while in care, may have occurred, however, there was not a preponderance of evidence to support or deny the allegation. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Otili Obuka, Administrator.

Investigation Findings:
13On July 2, 2024, at 3: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Obuka, Administrator to discuss the investigative finding for the above allegation. LPA Jauregui conducted an inspection of the facility on April 22, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S2-S4), one client (C1), and obtained pertaining documents. LPA was unable to interview S1 due to S1 no longer being employed by the facility. On April 15, 2024, the Department received the allegation that staff made inappropriate comments to a minor while in care. It was specifically reported that during a car ride S1 told C1 that if they had a knife, they would stab C1 with it. A confidential interview stated S1 did not like C1 and would treat C1 differently, and S1 did not like working with C1. Additional confidential statements disclosed that S1 treated C1 different than the other clients and S1 called C1 a "mofo" however there were no witnesses identified regarding the allegation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 07/02/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
It was also reported that C1 was taken to the hospital where C1 disclosed being sexually assaulted by a student at school. It was reported that C1 later changed the story and stated that they engaged in consensual intercourse with S1. Confidential interviews indicated C1 showed staff a letter in which C1 expressed feelings for S1. Confidential interview indicated C1 reported to staff having pain in their private area and C1 was taken to the hospital to be evaluated. Confidential interviews and records reviewed indicated C1 reported having sex with a student at school. Confidential interview and records reviewed indicated C1 retracted the statement and said C1 had sex with S1. The investigation did not yield witnesses to corroborate the allegation. Records reviewed did not provide evidence to support C1's allegation. Based on confidential interviews and records review, the allegation that staff engaged in inappropriate sexual behavior with a minor in care may have occurred, however, the allegation is not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided Kara Viliamu, House Lead.

Investigation Findings:
13On December 19, 2024, at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Kara Viliamu, House Lead to discuss the investigative finding for the allegation noted above. On October 2, 2024, Licensing Program Analyst (LPA) Lucero Jauregui conducted an initial complaint investigation visit. The investigation was conducted by Special Investigator (SI) Thomas Smith. SI Smith interviewed one client (C1), eight staff (S1-S8), one San Diego County Sheriff Detective and one Protective Services Social Worker. Pertinent records were obtained and reviewed. On September 30, 2024, Community Care Licensing (CCL) received an allegation that staff engaged in inappropriate sexual behavior with a minor in care. It was reported that S1 and C1 engaged in sexual intercourse at the facility. It was reported that C1 wrote S1 a letter in which C1 confessed their love for S1 and detailed alleged inappropriate interactions with S1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 12/19/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Kara Viliamu, House Lead


raw_content:
Narrative:
It was reported the minor got out of the pool, urinated, and walked around for another 5 minutes and left through the front gate of the home. It was reported the minor was unsupervised for approximately 20 minutes. Additionally, it was reported that on November 18, 2024, a minor attempted to gain access to the neighbor's home through the side gate, the back door, and then attempted to access the pool. Confidential interview indicated C1 got up at 4: AM on June 10, 2024 and ran out of the facility at 5: AM. Confidential interview indicated S1 was unable to follow C1 due to being the only staff for the overnight shift and not having a phone to call for assistance. Confidential interview indicated at around 6: AM, law enforcement came by and asked the facility about a missing client. Confidential interview indicated law enforcement picked up C1 with no clothing on, and C1 was returned to the facility in hospital clothes. Record review indicated the Sheriff's Department picked C1 up and transported C1 to a local hospital. Record review indicated C1 was brought back to the facility by C1's parents. Record review disclosed video footage of C1 swimming in a pool without staff supervision. Additionally, record review indicated C1 eloped to the neighbor's property on 3 more occasions. Based on confidential interviews, the allegation that staff does not provide adequate supervision to minor in care is SUBSTANTIATED because the preponderance of the evidence has been met. This posed an immediate health, safety, or personal rights risk to child in care. The facility is being cited for violation of Title 22, Division Chapter Article 06. Continuing Requirements 80078(a) Responsibility for Providing Care and Supervision [SEE LIC9099D]. An exit interview was conducted, and plan of correction was developed with Kara Viliamu, House Lead. A copy of this signed report, LIC 9099D, and appeal rights were provided to Kara Viliamu, House Lead.

Investigation Findings:
13On February 19, 2025 at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Kara Viliamu, House Lead to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on July 2, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed one client (C2) and three staff (S1-S3). LPA was unable to interview one client (C1) due to client's limited verbal abilities. Pertinent documents were obtained. On June 24, 2024, Community Care Licensing (CCL) received an allegation that staff does not provide adequate supervision to minor in care. It was reported that at around 4:00 to 5: AM a minor was seen climbing a 5 to 6 feet fence and walked to the backyard of a neighbor. It was reported that the minor removed their clothing, and jumped into a 10 feet deep pool. It was reported that the minor was in the pool for approximately 5 minutes and appeared to be struggling. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 02/19/2025

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


raw_content:
Narrative:
Confidential interview indicated incidents are documented on an internal application used by the facility. Confidential interview indicated incident reports are done by the administrator from what is being documented on the application. Record review indicated that on June 10, 2024, C1 absconded from the facility, C1 was picked up by law enforcement and was taken to a local hospital. Record review indicated that on June 16, 2024, and on June 30, 2024, a report was made to law enforcement in regard to C1 being left outside in the backyard knocking on the door and not being allowed inside. Record review indicated incident reports were not provided to CCL. Record review indicated that on November 18, 2024, C1 eloped from the facility and went into the neighbors' home attempting to jump in the pool. Record review and confidential interview indicated staff prevented C1 from jumping into the pool by restraining C1. Record review indicated that the incident was reported to CCL; however, the report did not disclose that the client had been restrained. Based on confidential interviews and record review, the allegation that licensee does not ensure unusual incident reports are submitted is SUBSTANTIATED because the preponderance of the evidence standard has been met. This posed a potential health, safety, or personal rights risk to child in care. The facility is being cited for violation of Title 22, Division 6, Chapter 5, Subchapter 3. Emergency Intervention in Group Homes 84061(a) Documentation and Reporting Requirements [SEE LIC9099D]. An exit interview was conducted, and plan of correction was developed with Otili Abuka, Administrator. A copy of this signed report, LIC 9099D, and appeal rights were provided to Otili Abuka, Administrator. It was reported that the other residents in the home have to ask staff anytime they want something to eat, and staff make up excuses to avoid going out to the refrigerator in the garage. It was also reported that staff often leave the medication closet unlocked. It was reported that staff are reprimanded when it is left unlocked; however, there are no consequences. Additionally, it was reported that a client jumped over the backyard fence, went into a neighbor's house, and ate food from the refrigerator. It was reported that facility staff are withholding food from residents. Confidential interviews indicated C1 is a food seeker. Confidential interview indicated when C1 looks in the refrigerator, C1 often wants to move and eat everything. Confidential interview indicated much of the food in the refrigerator from inside the facility was relocated to the refrigerator in the garage; however, food was still made available to clients. Confidential interviews indicated meals and snacks are provided. Confidential interviews denied food is being withheld. It was reported that facility staff are not keeping centrally stored medications locked up. Confidential interviews indicated medication has remained locked. Confidential interviews denied medication being accessible to clients. Based on confidential interviews, the allegations facility staff are withholding food from residents and facility staff are not keeping centrally stored medications locked up may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Otili Abuka, Administrator

Investigation Findings:
13On March 5, 2025 at 1: PM, Licensing Program Analysts (LPA's) Lucero Jauregui and Abby Saeteurn arrived at the facility unannounced and met with Otili Abuka, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on July 2, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed one client (C2), three staff (S1-S3) and two witnesses (W1-W2). LPA was unable to interview one client (C1) due to client's limited verbal abilities. Pertinent documents were obtained. On June 28, 2024, Community Care Licensing (CCL) received an allegation that licensee does not ensure unusual incident reports are submitted. It was reported that when staff use Crisis Prevention Institute (CPI) restraint on the clients, the administrator does not submit incident reports to CCL. Additionally, it was reported that an incident report was not filed with CCL when C1 absconded from the facility and was returned to the facility by the police. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 03/05/2025

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Otili Abka, Administrator


raw_content:
Narrative:
Confidential interview indicated S1 and S2 were in the kitchen and C1 became aggressive towards staff. Confidential interview indicated S2 attempted to help S1, however S2 was unsuccessful. Confidential interviews indicated S1 and C1 were left in the house alone. Confidential interview indicated, subsequently, C1 was observed lying on the floor with S1 on top of C1. Confidential interview indicated S1 was holding C1's hand and handling C1 in an aggressive manner. Confidential interviews indicated that after the incident C1 was observed to have blood in their mouth area. Based on confidential interviews, the allegation that facility staff handle minor in a rough manner is SUBSTANTIATED because the preponderance of the evidence standard has been met. This posed immediate health, safety, or personal rights risk to youth in care. The facility is being cited for violation of Title 22, Division 6, Chapter Subchapter 3. Emergency Intervention in Group Homes Article 08. Emergency Intervention in Group Homes 84300.1(b) Emergency Intervention Prohibition. [See Lic9099d]. An exit interview was conducted and plan of correction was developed with Otili Abuka, Administrator. A copy of this signed report, LIC 9099D, and appeal rights were provided to Otili Abuka, Administrator. Confidential interview indicated C2 had scars from fighting staff. Confidential interview indicated C2 is placed in holds when they are throwing tantrums or when C2 is feeling unsafe. Confidential interview indicated C2 is placed in holds by various staff when engaging in unsafe behavior. Confidential interview indicated the scars were observed to be deep scars, however, they were not observed to be new or fresh. Confidential interviews did not provide corroborating statements and there were no witnesses to a physical staff altercation with C2. Based on confidential interviews and records reviewed, the allegation that facility staff engaged in a physical altercation with a minor may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Otili Abuka, Administrator.

Investigation Findings:
13On March 26, 2025 at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Abuka, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on August 20, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S1-S3), one client (C2), and one witness. LPA attempted to interview C1 but was unable to obtain a statement due to child's limited verbal abilities. Pertinent documents were obtained. On August 14, 2024, Community Care Licensing (CCL) received an allegation that facility staff handle minor in a rough manner. It was reported that on 8/12/ C1 got into a verbal altercation with staff. It was reported that staff was either shaking or hitting C1. It was reported that S2 watched the incident. It was reported that C1 got up and had redness or blood under their nose. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 03/26/2025

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Otili Abuka, Administrator


raw_content:
Narrative:
Confidential interviews indicated when C2 engages in a behavior or is showing aggression, clients are prompted to go to their bedrooms. Confidential interviews indicated, on 8/30/2024, C2 engaged in a behavior in the hallway where client bedrooms are located. Confidential interviews indicated C2 was swinging their arms as clients were going to their bedrooms; however, interviews did not indicate that C2 made contact with either of the clients. Confidential interview also indicated C2 engaged in property destruction and banging on bedroom doors. Confidential interviews indicated C2 is not aggressive towards clients but is aggressive towards staff. Confidential interviews did not provide corroborating statements and there were no witnesses to an altercation between children in care. Based on confidential interviews and records reviewed, the allegation that staff did not prevent an altercation between children in care may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Otili Abuka, Administrator.

Investigation Findings:
13On March 26, 2025 at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Abuka, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on September 10, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed two staff (S2-S3), and two clients (C2-C3). LPA attempted to interview C1 but was unable to obtain a statement due to child's limited verbal abilities. Pertinent documents were obtained. On September 3, 2024, Community Care Licensing (CCL) received an allegation that staff did not prevent an altercation between children in care. It was reported that on 8/30/24, C2 punched C1 in the chest and C1 couldn't breathe. It was reported that C2 destroyed C1's personal property. It was reported that C1 tried to seek comfort from staff, and they didn't help. It was reported that the name of the staff members is unknown. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 03/26/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


raw_content:
Narrative:
Confidential interviews and record review indicated that on 8/16/24, C1 was placed in a low Crisis Prevention Intervention (CPI) hold, that is not approved on C1's behavior plan. Confidential interviews continued to state staff placed C1 in inappropriate restraints with C1 face down on the floor and staff crouched over C1. Confidential interview indicated C1 engaged in a behavior that led into C1 running into the garage. Confidential interview indicated two staff members went hands on C1 and attempted to carry C1 back into the facility. Confidential interview indicated C1 did not want to be placed on in a hold, flopped their body weight to the ground, and staff dragged C1 back inside the facility by their feet. Confidential interviews indicated staff are quick to place C1 in a CPI hold. Confidential interviews indicated there is no verbal re-direction and no coping skills offered while C1 is placed in holds. Record review disclosed video footage of C1 placed in a restraint in which C1 was observed to be face down with staff holding C1's hands behind their back. Based on confidential interviews and records reviewed, the allegation that staff are using improper restraint techniques on minors in care is SUBSTANTIATED because the preponderance of the evidence standard has been met. This posed potential health, safety, or personal rights risk to youth in care. The facility is being cited for violation of Title 22, Division 6, Chapter Subchapter Emergency Intervention in Group Homes 843001.1(b) Emergency Intervention Prohibition. [See Lic9099d]. An exit interview was conducted, and a plan of correction was developed with Otili Abuka, Administrator. A copy of this signed report, LIC 9099D, and appeal rights were provided to Otili Abuka, Administrator.

Investigation Findings:
13On May 14, 2025 at 12: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Otili Abuka, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on September 26, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed two staff (S1-S2), one client (C1), and five witnesses (W1-W5). Pertinent documents were obtained. On September 19, 2024, Community Care Licensing (CCL) received an allegation that staff are using improper restraint techniques on minors in care. It was reported that staff are putting residents in improper holds, in a prone position, sitting on residents, and putting knees on residents' backs. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 05/14/2025

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


raw_content:
Narrative:
Confidential interview indicated it had been brought up in the past of that a staff member threatened C1 out of the car. According to confidential interview, the staff who allegedly threatened C1 no longer works at the facility. Confidential interviews indicated S2 spoke inappropriately to and was physically aggressive toward C1 and C3. Confidential interview indicated S2 spoke to the clients using profanity. Confidential interview indicated S2 did not transport clients while working at the facility. Confidential interviews indicated S2 was placed on leave and did not return. Although interviews indicated that staff spoke inappropriately to clients in care, confidential interviews did not provide corroborating statements of staff threatening minors in care. Based on confidential interviews, the allegation that staff threaten minor(s) in care may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this signed report and appeal rights were provided to Alan Kana, Facility Representative

Investigation Findings:
13On July 1, 2025 at 12: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Alan Kana, Facility Representative to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on October 22, 2024, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed one client (C1) and four staff (S1-S4). LPA attempted to interview two staff (S5-S6), however, after numerous attempts LPA was unsuccessful. LPA attempted to interview C3 but was unable to due to the child's limited verbal abilities. Pertinent documents were obtained. On October 21, 2024, Community Care Licensing (CCL) received allegation that staff threaten minor(s) in care. It was reported that some staff verbally threatened to harm C1. Specifically, in April 2024, a staff threatened C1 to throw C1 out of a car and in June 2024, a male staff threated to send C1 to the hospital with a black eye. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 07/01/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Alan Kana, Facility Representative


raw_content:
Narrative:
It was reported that C1 was able to grab the key from the counter, used it to open the medication cabinet accessing C1's melatonin gummies and ingested ten more gummies before being stopped by staff from taking more. It was reported that, in response, C1 received medical attention Confidential interviews indicated S1 was administering medication to another client (C2) and C1 reached over S1 and consumed an extra dose of their own medication (melatonin). Confidential interviews indicated S1 locked up all the medication and placed the keys on the counter. Confidential interviews indicated C1 grabbed the keys from the counter, quickly identified the key to the medication cabinet and opened the cabinet. Confidential interviews indicated C1's medication was on the bottom shelf of the cabinet and C1 grabbed the bubble pack of their melatonin and ran outside into the backyard with the pack. Confidential interviews indicated S1 and S2 ran after C1 and attempted to verbally re-direct C1. Confidential interviews indicated S2 informed S1 of the need for a Crisis Prevention Intervention (CPI) hold and C1 dropped the bubble pack after having consumed the extra medication. Based on confidential interviews and record review, the allegation that due to lack of supervision, minor was able to obtain the medication key and access the medication cabinet resulting in minor ingesting medications is SUBSTANTIATED because the preponderance of the evidence standard has been met. This posed an immediate health, safety, or personal rights risk to youth in care. The facility is being cited for violation of Title 22, Division 6, Section 80075(k)(1) Health Related Services. [See Lic9099d]. An exit interview was conducted and a plan of correction was developed with Alan Kana, Administrator, AnnMarie Stanton, District Manager and Barbara Dousette, Quality Support Speciality and Trainer. A copy of this signed report, LIC 9099D and appeal rights were provided to Alan Kana, Administrator.

Investigation Findings:
13On October 16, 2025 at 11: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Alan Kana, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on June 11, 2025, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed three staff (S1-S2, S4), one client (C1), and one County Social Worker (CSW). Pertinent documents were obtained. On June 10, 2025, Community Care Licensing (CCL) received allegation that due to lack of supervision, minor was able to obtain the medication key and access the medication cabinet resulting in minor ingesting medications. It was reported that S1 left the key to the medication cabinet unattended on the counter. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 10/16/2025

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Alan Kana, Administrator, AnnMarie Stanton, District Manager & Barbara Dousette, Quality Support Speciality and Trainer


raw_content:
Narrative:
Confidential interviews indicated C2 engaged in a behavior and, while upset, went into C1's bedroom. Confidential interviews indicated C1 became upset and yelled and cursed at C2 to get out of their bedroom. Confidential interview indicated S2 was verbally redirecting C2 and C2 was able to get out of C1's bedroom safely. Confidential interviews indicated C2 was at the door of their bedroom and C1 attacked C2 with a tennis racket C1 obtained in their bedroom. Another confidential interview indicated the tennis racket was in the living room. Confidential interviews indicated S2 was standing between C1 and C2 attempting to block the racket swings and verbally redirecting C1. Confidential interviews indicated S1 was preparing a snack for C2 during the incident. Although the investigation revealed that the incident occurred, evidence did not indicate that the assault occurred due to lack of supervision. Based on confidential interviews and records reviewed, the allegation due to lack of supervision, minor assaulted another minor is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Alan Kana, Administrator.

Investigation Findings:
13On October 16, 2025 at 10: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Alan Kana, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on June 11, 2025, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed four staff (S1-S4) and one client (C1). LPA attempted to interview C2 but was unable to obtain a statement due to child's limited verbal abilities. Pertinent documents were obtained. On June 9, 2025, Community Care Licensing (CCL) received allegation that due to lack of supervision, minor assaulted another minor. It was reported that on June 7, 2025, C2 was experiencing self-injurious behavior due to the internet being out of service. It was reported that C1 saw C2 entering C1's bedroom, at which time C1 grabbed a tennis racket and used it to hit C2 on top of their head. It was reported C2 did not sustain any visible injuries. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 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 Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: PEOPLE'S CARE RESMARFACILITY NUMBER: VISIT DATE: 10/16/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


summary: Facility Evaluation

raw_content:
Narrative:
On April 28, 2022 at 9: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced inspection at the facility above. LPA met with Program Administrator (P1) Levy Middlebrooks. The purpose of the inspection is to conduct a required annual inspection. LPA inspected physical plant, operational requirements, disaster preparedness, emergency intervention plan and reviewed three client files (see confidential name list, LIC811, dated 04/28/2022). The client files are stored and locked in a cabinet in the office. Medication is kept in a locked cabinet and centrally stored. The client file review was not completed during inspection due to time constraint. Due to time constraints, the annual inspection is being extended for completion of client file reviews, staff file reviews, staff interviews and client interviews. LPA conducted 0 of 4 staff interviews and 0 of 3 client interviews. Based on client record review, the licensee did not comply as 3 out of 3 client's (C1, C2, C3) psychotropic medications were not listed on a separate logs for each psychotropic medication prescribed for the child and 1 (C3) out of 3 client's(C1-C3) did not have a signed copy of admission agreement which posed a potential Health, Safety or Personal Rights risk to clients in care. The facility is being cited for California Code of Regulations, Title 22: CCR 84070(b)(13) and CCR 80070(b)(6) An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Program Administrator Levy Middlebrooks and a copy of this report was provided.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On May 04, 2022 at 12: PM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced annual continuation inspection at the facility above. LPA met with Program Administrator (P1) Levy Middlebrooks. The purpose of the inspection is to conduct a required annual inspection. LPA reviewed 3 of 3 client files and 6 of 6 facility staff files. Files are maintained on-site and locked in cabinets in the office. LPA conducted 3 of 3 staff interviews and conducted a safety inspection. LPA was unable to interview 3 of 3 clients due to 3 clients were unable to answer LPA questions. (see confidential name list, LIC811, dated 04/28/2022). Based on client record review, the licensee did not comply as 3 of 3 clients original need and services plan; verification, were not signed by the child and his/her authorized representative(s), that they were offered the opportunity to participate in plan development; and verification that the authorized representative(s) have approved the plan which posed a potential Health, Safety or Personal Rights risk to clients in care. The facility is being cited for California Code of Regulations, Title 22, 84707(C)(1). An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Program Administrator Levy Middlebrooks and a copy of this report was provided.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst's (LPA's) Leslie Covarrubias and Eduardo Barragan on November 03, 2022 at 11: AM. During the inspection, LPAs Covarrubias and Barragan met with Administrator, Levy Middlebrooks and inspected the facility inside and out. LPA's reviewed three of three child's records on site at the facility at 12: PM. LPA's reviewed two of two staff personnel files on site at the facility at 1: PM. LPA's interviewed one of two staff on site at 2:20PM. LPA's interviewed three of three children currently taking psychotropic medication at there schools after this inspection was conducted at the facility. LPA's conducted exit interview with Administrator, Levy Middlebrooks at 2:50 pm No deficiencies were cited at this time. LPA's provided the Summary Report and appeal rights to Administrator, Levy Middlebrooks upon completion.

met_with: Levy Middlebrook, Administrator