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Narrative:
Continued from LIC 9099... During interviews, six staff members explained they received adequate and extensive training from a Licensed Vocational Nurse (LVN), on how to maintain medication logs, use sterile procedures, and properly store medication. They also reported having job shadowed the process. The staff's descriptions of the training align with the program statement training procedures. One staff member, however, disclosed feeling uncomfortable administering medication because they had only job shadowed prior to being expected to administer themselves, which does not meet the expectations outlined in the facility program statement training procedures. This staff member, however, was initially hired and trained at the Kenneth, People's Care facility, which will be addressed separately. Based upon the comparison between the amount of staff members (5) interviewed who stated that staff do not raise their voice and the one staff who stated they do, as well as upon the evidence of non-violent crisis and de-escalation training taken, the allegation "Staff yell at minors in care," cannot be proven true. Furthermore, based upon the amount of staff members interviewed (6) who stated they received adequate training for administering medication as well as upon the verification of medication provided by file review, the allegation "Unqualified staff are passing out medication," cannot be proven true. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated. Exit interview was completed virtually with administrator, Rodina Ventura, and appeal rights explained, on 6/14/21 at 11:00 am. LPA emailed 9099 and appeal rights to be signed and sent back. There will be a hard copy kept in paper file.

Investigation Findings:
13Licensing Program Analyst (LPA), Stefanie Whitlow, conducted complaint investigation for the allegations stating, "Staff yell at minors in care" and "Unqualified staff are passing out medication." LPA conducted interviews with seven staff members, completed facility inspection, using video technology, and reviewed documents pertaining to personnel training requirements as outlined in the program statement plan of operation. All staff members interviewed explained that the extensive training they received in non-violent crisis intervention prepared them well for deescalating challenging clients. One staff member revealed they have observed other staff yelling at clients. Five staff members shared, during interviews, that they communicate with clients without raising their voice. Those five were also able to explain how they redirect clients and use positive reinforcement to avoid escalation. One staff member disclosed that they attempt to match the volume of the client's voice, when raised, in order to communicate. The record review provided evidence of staff completing non-violent crisis intervention training. Continued on LIC 812-C... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Stefanie Whitlow 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 23-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, COHASSET RD., SUITE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 06/14/2021


state: CA

facility_name: PEOPLE'S CARE PLEIDES

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews with S1, S2, S3 and S4 corroborate that staff has not engaged with minors in an inappropriate manner. C1 stopped interview prior to answering all questions. LPA Goldie attempted to contact previous Program Administrator, who relocated out of state, with assistance from the Investigation Bureau but, was unable to gain accurate contact information. C2 and C3 are non-verbal and unable to be interviewed. LPA determined insufficient evidence was provided to support whether staff engaged in an inappropriate manner with minor or not. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No citations were issued today. An exit interview was conducted with Daniel Anderson at 11: AM. A copy of this report along with appeal rights were discussed and provided.

Investigation Findings:
13On 06/17/2022, Licensing Program Analyst (LPA), Connie Goldie met with Lead Facility Manager, Daniel Anderson at 11: A and explained the purpose of the visit was to deliver complaint findings for the above allegation. LPA Alyssa Burgess initiated the complaint at the above named facility on 02/25/2022 and met with staff Daniel Anderson regarding a personal rights violation allegation. During the course of the investigation, LPA Goldie investigated the complaint that "Staff engaged with minor in an inappropriate manner" LPA Goldie conducted a records review of documentary evidence on 03/30/2022. LPA Goldie conducted a physical plant inspection of the home on 04/01/2022 and interviewed three staff. Lead staff 2 stated that both clients in care are non-verbal and Program Administrator confirmed this to be true. LPA Goldie interviewed C1 on 04/01/2022. LPA Goldie interviewed one staff on 05/19/2022. LPA Goldie attempted to contact previous Program Administrator on 06/01/2022 but, contact information is incorrect. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie 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 23-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, NATOMAS PARK DR., STE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 06/17/2022

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

report_type: Complaint Investigation

met_with: Lead Facility Manager Daniel Anderson

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
An attempted interview with Foster Youth on 2.28.2023.LPA was unable to interview Reporting Party due to multiple calls with no return phone call. Interview with Administrator stated that there were problems with communication with the old Administrator in that when the Foster Youths school would call the Administrator they would not get a return call back. The Administrator has since given the School Director her cell number that she can call to discuss the care of the Foster Youth. Interview with Staff 1, Staff 3, Staff 4, and Staff 5 all stated that the new Administrator has been in communication with the school Director since she has started the position at the facility. LPA was not able to interview School Director/Reporting party as multiple phone calls were made where the LPA left her number for a return call, but the calls were not returned. As a result of the investigation and interviews conducted, the allegations that staff are not available to provide information about client's care is SUBSTANTIATED at this time meaning that the preponderance of the evidence standard has been met. An exit interview was conducted with Quinisha silva, DSP 2. A copy of the report and the appeal rights were provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA)Jennifer Baca arrived at the agency to conduct an unannounced complaint inspection on 3.14..2023 at 12: Pm. LPA Baca spoke with Quinisha SIlva, DSP 2 to discuss the findings of the complaint investigation and allegations stated above. LPA informed agency staff this case was investigated by LPA Baca. The initial 10-day complaint investigation inspection was conducted at the agency on 2.21.2023. Documents were obtained on 2.21.2023, including staff schedule, staff training record, and staff contact information. Documents regarding foster Youth included the needs and services, and daily activity schedule. Interviews were conducted with the Administrator of 2.21.2023, Staff 1 or 2.24.2023, Staff 3 or 2.24.2023, Staff 4 on 2.28.2023. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Jennifer Baca 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 03/14/2023

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

met_with: Quinisha Silva, DSP2

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Administrator Hamilton stated the facility has a regular training schedule that has been implemented for all staff. LPA Baca observed training records of staff and compared these records to staff members on the LIC500. LPA Baca noted that staff had been trained appropriately. As a result of the investigation and interviews conducted, the allegation staff are not properly trained is unsubstantiated meaning the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. LPA Baca investigated the allegation that facility staff did not intervene when a resident engaged in inappropriate behaviors. Interviews with Administrator, S1, S2, S3, S4 and S5 all stated that they redirect C1 when inappropriate behaviors are occurring. Staff will redirect C1 to his bedroom or the bathroom. Interviews with S1, S3, S4 and S5 stated that the inappropriate behaviors do not happen very often, but when they do, C1 is able to be redirected. Interview with Administrator confirmed staff's statements and Administrator confirmed that C1 is redirected to their bedroom when inappropriate behaviors happen. The specific incident provided by RP could not be corroborated by staff. LPA Roberts interviewed C2 on 7/11/23 and C1 on 7/17/23. Based on the investigation, observations, information reviewed, and interviews conducted, the complaint allegation that facility staff did not intervene when the client engaged in inappropriate behaviors is unsubstantiated, meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. End of report.

Investigation Findings:
13On 7/17/2023 at 1:00 p.m. Licensing Program Analyst (LPA) Monica Roberts and Licensing Program Manager (LPM) Jodean Hall arrived at the facility to conduct an unannounced complaint inspection. LPA spoke with Kourtney Hamilton, Administrator, to discuss the findings of the complaint investigation and the allegations stated above. The complaint was investigated by LPA Jennifer Baca and LPA Monica Roberts. The initial 10-day complaint investigation inspection was conducted on 2.21.2023. Staff and client records were obtained, included but not limited to staff schedule, training records, Individual Program Plan and Needs and Services Plan for Client 1 (C1), activity schedule, prescription documentation, daily notes, incident reports, and C Personal. Interviews were conducted with the administrator, Kourtney Hamilton, S1, S3, S4 and S5 between 2/21/2023 and 2/27/23 and S6 on 6/2/2023. LPA Roberts interviewed C2 on 7.11.23 and C1 on 7.17.23. LPA Baca investigated the allegation that facility staff are not properly trained. Interviews with Administrator, S1, S3, S4 and S5 all stated they are trained appropriately to conduct the duties of the job.(continued on LIC9099 - C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Monica Roberts 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 07/17/2023

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

met_with: Kourtney Hamilton, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Document was created in error. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Monica Roberts 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 07/17/2023


raw_content:
Narrative:
Investigation demonstrated that C1 originally alleged that S1 "punched" them with a closed fist but when C1 was interviewed, they were unresponsive to questions being asked and did not specify how their injuries were sustained. Other interviews indicated that C1 has aggressive tendencies toward staff including charging at them, spraying water and soap on the kitchen floor causing the floor to be slippery so staff would fall if attempting to follow C1 throughout the facility and outside. In addition, C1's additional behaviors include punching holes in wall(s), causing property damage throughout the facility, self harm, including banging their head on walls, door frames, and scratching themselves, to name a few. Interviews with other staff members present during the alleged incident denied seeing S1 be aggressive towards C1 or strike C1 in any way. All individuals present indicated that C1 had sprayed water and soap on the kitchen floor causing it to be slippery, resulting in C1 falling several times during the alleged incident, hitting their face and body, sustaining the described injuries. Staff interviewed also indicated that the facility is "hands off" meaning their protocol is to evade client aggression and to not engage in restraints for their safety and the safety of clients in care. Facility staff are currently being trained in a different behavior intervention program but will continue to not restrain clients in care. As a result of the investigation, interviews conducted, and documentation reviewed, the allegation that staff physically assaulted client (C1) which resulted in injuries is UNSUBSTANTIATED meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. McGill and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 6/5/24 at 3: PM and met with Diane McGill, Administrator to discuss the complaint findings as stated. LPA Hill informed Ms. McGill that the investigation included an initial inspection on 4/17/24 where documents were obtained for C1 and C2 (see LIC811 dated 6/5/24) and other documents were requested regarding staff that work in the facility. The investigation and interviews were conducted by the Department's Investigation Branch, Investigator Melissa Bennett. The investigator interviewed two clients, four staff, an interview with staff at C1's school, and two Alta California Regional Center staff as part of the investigation. The allegation that staff physically assaulted a client (C1) which resulted in injuries is related to an incident that took place in the facility on or about 4/8/24 where C1 suffered injuries of their eye, lip, and chest area. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 06/05/2024

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

met_with: Diane McGill, Administrator


summary: Complaint Investigation - Unsubstantiated

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Narrative:
On 7/24/2024, when LPA was inspecting the client's room, a staff was in their bathroom mopping. When LPA entered the bathroom, a strong scent of marijuana was present. When LPA interviewed that staff, he denied being high and denied smoking at the facility. The staff stated the smell is probably from their jacket, when they smoked in their own free time. During interviews with staff, LPA was informed by the two staff who were smoking in front of the client the day of the picture being taken, that it was only a nicotine vape, that sometimes the client is out there with them, but they try to have the client go inside. The other staff that was in the picture initially denied anyone smoking in front of the client, but when showed the picture and asked about it, stated that on a rare occasion the client will be out there, but not usually. All three staff denied smoking marijuana at the facility, or staff being high while working. The staffs' stories were corroborative in that two staff share a nicotine vape, and since the job is stressful, they will take a puff on the nicotine vape outside. LPA also learned through interviews with staff that one of their neighbors makes frequent unreasonable complaints about the facility. LPA was informed by staff that when they would go out front to smoke, the neighbor would complain, so they did it in the backyard instead. One staff showed LPA the vape he uses and it is a disposable nicotine vape. The staff demonstrated to LPA the puff from the vape and it had no scent of marijuana, only flavoring, like a nicotine vape. During an interview with a staff, LPA learned that the client's marijuana vape pen smells of marijuana when smoked. Due to staff smoking on facility property and in the presence of a client, the facility is being cited for a violation of the California Code of Regulations, Title 22, Division 6, Chapter 5, Buildings and Grounds, 84087(c). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with QA/Admin and a copy of this report and appeal rights was provided to her.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannouced complaint investigation inspection at the facility and met with Gina Renteria, Quality Assurance/Interim Administrator, who assisted with the inspection. LPA investigated this complaint by reviewing security video footage, pictures, emails, smelling the vape vapor, observing the vape unit the staff had, and by interviewing the Reporting Party/witness, three other witnesses, four staff, and the Administrator on 7/29/2024. The pictures LPA reviewed showed three staff outside in the facility backyard smoking in front of a client. All witnesses and the reporting party stated they smell marijuana and stated that it is coming from the facility. The witnesses stated the staff are smoking the marijuana, however, only one of them were able to ever see the staff smoking anything. The three other witnesses have not seen the staff smoking, but smell marijuana in the general vicinity. None of the witnesses know that the client there does smoke from a marijuana vape, per prescription. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 08/13/2024

met_with: Gina Renteria


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
During an interview with C1's parent (W1), LPAs were informed that W1 has been paying the facility via Cashapp to reimburse their spending on C1's THC vape pens up until June 2024, and provided screenshots of these transactions. Based on a review of C1's cash resource records by the facility for April, May, and June 2024, there were no recordings of any vape purchases or reimbursements completed by the facility. LPA Goldie reviewed C1's July 2024 cash resources log in-facility on 8/13/2024, and then again in-facility on 8/28/2024 which showed that seven more entries were added to the log after 8/13/2024. This included four entries for "reimbursements," which indicated the facility reimbursed themselves for past vape purchases. Two of those noted vape reimbursements on 7/6/2024 did not correlate to any receipts, and amounted to $60. In addition to this, noted on 7/22/2024 there were three entries for "state fair": $39, $20, and $8 for which there were no receipts. C1 had been receiving checks from Social Security in their name. Beginning in January 2024 the checks began to accumulate at the facility. On 6/3/2024, LPA received photos of the checks that were present in the facility which were for 1/2024, 2/2024, 3/2024 4/2024, and two checks for 5/2024, totalling $7,480. Interviews with Administrator and Program Director informed LPA that the facility did not know what they were for. During LPA Goldie's inspection at the facility on 8/28/2024 she observed checks for 2/2024, 3/2024, 4/2024, two checks for 5/2024, and a check for 8/2024. There were three missing checks: 1/2024, 6/2024, and 7/2024. Based on records review, the facility cashed the 1/2024 check, and either the 6/2024 or 7/2024 check. Two checks were cashed; however, three checks were missing with one unaccounted for. On 7/9/2024 and 7/18/2024, C1 was taken to a check cashing business and was charged $23.76 each time to cash the checks. Based on LPAs' interview with W1 and review of the conservatorship paperwork, W1 is the limited conservator for C1. However, W1 informed LPAs that they were never made aware that C1 had money, that the facility cashed any of C1's checks, that the facility had spent any of C1's money, and was unaware that the facility was using C1's money to pay for the THC vapes. During LPA's interview with SC, LPA was informed that SC had been requesting a doctor's certification form that C1 needed to enlist W1 as the payee due to C1 not being able to manage their own money, from the facility for, "a long time... at least the beginning of this year." It was not until C1's day of discharge on 9/23/2024 that the visit was completed and the form was signed. SC also informed LPA that at the beginning of the year, the Administrator at the time missed an SSI appointment to get it set up, and then when the subsequent Administrator took over, they failed to complete this as well. SC also informed LPA that the facility failed to bill for P&I moneys for C1, which C1 could have been utilizing during the length of C1's placement. Interviews with the current Administrator and Program Director informed LPA that W1 was unresponsive to them which made it difficult for them to cash the checks and attain an ID for C1. However, LPAs were informed by W1 that they visited the facility about monthly, and called the facility every Wednesday; in which case the facility would have had many opportunities to communicate with W1. Upon review of facility visitor logs for 2023 and 2024, W1 signed in on four dates: 8/12/2023, 10/21/2023, 1/13/2024, and 3/15/2024. W1 informed LPA Goldie that W1 did not sign in every time. Additionally, W1 has been highly responsive to LPAs and SC, so it is unclear if W1 was truly unresponsive to the facility. Based on LPAs' records reviewed and conducted interviews, the preponderance of the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, Sections 80078(a) and 80022(k) are being cited on the attached LIC 9099D. An exit interview was conducted with PD and a copy of this report, appeal rights, and confidential names list were provided to him.

Investigation Findings:
13Licensing Program Analysts (LPA) Alyssa Burgess and Connie Goldie made an unannounced complaint investigation 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. LPA investigated this complaint by reviewing client records and conducting confidential interviews with the Administrator, Program Director, the Regional Center Liaison, Regional Center Service Coordinator (SC), and a client's parent between 5/31/2024 and 10/7/2024. LPA Connie Goldie conducted an interview with the facility's Quality Assurance staff and collected client receipts. Both LPAs collected client cash resource records and took photos of uncashed checks for client C1 (See Confidential Names List dated 10/15/2024). It was alleged that the Administrator comingled C1's funds in their own bank account. LPA was informed by PD that Administrator did offer to do so in an attempt to get C1 their money, however did not do so as it is not allowed. Although PD confirmed Administrator offered to do this, Administrator denied that she did to LPA. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 10/15/2024

met_with: John O'Brien


raw_content:
Narrative:
During the investigation, twelve confidential interviews were conducted between 08/06/2024 and 10/03/2024. C1 was unable to be interviewed due to cognitive disabilities. Regarding the allegation, "Staff neglect resulting in client had access to a firearm," Sacramento County Sheriff's police report confirmed that C1 was in the facility van with S1 and S2 on 07/30/2024 when it was pulled over. Axon Body Cam footage reviewed by Investigator revealed that the loaded firearm was found in the third row of the van on the passenger side of the van, sitting directly next to C1 which provided C1 access to a firearm. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Health and Safety Code HSC 1558(a)(2) Conduct Inimical are being cited on the attached LIC 9099D." The Department investigated the allegation, Conduct Inimical: Staff was arrested for unlawful possession of a firearm. S1 stated in interview that S2 was arrested for obtaining a loaded firearm in presence of C1. In Sacramento County Sheriff's Department report it was confirmed that S2 was arrested for having an unlicensed loaded firearm which S2 admitted belonged to him. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Health and Safety Code 1558(a)(2) Conduct Inimical, was cited on the previous allegation. Regarding the allegation, Staff transports client without a valid driver's license, the Administrator admitted to not verifying that staff driving the facility van were approved, stating "I dropped the ball, and didn't get the driver approval list." Record review of driver approval list indicates that only three staff members were allowed to transport clients and S1 wasn't on the list. S1 the staff driving C1 on 07/30/2024 during traffic stop did not have a valid driver's license according to police report. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Title 22, Division 6, Chapter 1 80066(a)(2) Personnel Records are being cited on the attached LIC9099D. Continued on LIC C The Department investigated the allegation, "Staff exposed client to smoking and drinking," Five of seven staff interviewed stated there is a no tolerance policy for smoking and drinking and they recently received training within the past couple of weeks. Two staff of seven stated there was a situation when staff vaped on the porch in front of a client one time. Staff said he has already received discipline for this incident. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. The facility was cited for this referenced incident on 08/14/2024 under complaint control # 23-CR-20240723120212 therefore, will not be cited for this allegation. An exit interview was conducted. A copy of all reports and appeal rights were provided and discussed with agency representative, John O'Brien. During the investigation, twelve confidential interviews were conducted between 08/06/2024 and 10/03/2024. C1 was unable to be interviewed due to cognitive disabilities. The Department investigated the allegation, Administrator and staff are drinking and smoking in presence of client. Seven of eight staff interviewed stated they have not observed staff and/or drinking and smoking in front of a resident. The Administrator denied the allegation as well. Therefore, it isn't possible to determine if the allegation occurred or not. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated." Regarding the allegation, Client is being financially abused, record review of Personal and Incidental receipts for July and August 2024 and corresponding Cash Resource Ledgers indicates that C1 paid his portion of the bowling alley cost on 07/13/2024 which was $100.70 of the total bill which was $279.68. Six of seven staff interviews corroborate that the cost of the outing was split, and staff paid for their portion. One staff stated that C1 didn't pay for any of it. During record review, LPA observed on 8/28/ C1's checks for 2/2024, 3/2024, 4/2024, two checks for 5/2024, and a check for 8/2024. There were three missing checks: 1/2024, 6/2024, and 7/2024. Based on records review, the facility cashed the 1/2024 check, and either the 6/2024 or 7/2024 check. Two checks were cashed; however, three checks were missing with one unaccounted for and there were missing receipts for purchases made by C1 on the following date 07/22/2024. W1 supplied receipts for reimbursements to the facility for vape pens but, these were not documented on C1's safeguarded cash resource ledgers. Therefore, it isn't possible to determine if allegation occurred or not. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated." Continued on LIC9099C Regarding the allegation, Staff took C1 to a strip club, one staff said C1 was taken. 6 of 8 confidential interviews stated C1 said he wanted to go to a strip club but, did not corroborate that he was taken. One staff stated they had no knowledge of C1 wanting to go or being taken to a strip club. One staff said they believed C1 was taken to the strip club but, do not have evidence that it occurred. Therefore, it isn't possible to determine if the allegation occurred or not. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated." The Department investigated the allegation, Failure to report. C1 stated they did not communicate to anyone that they were pulled over or that C2 had been arrested. PA denied being aware that C1 was in the facility van when a traffic stop occurred or anything about an arrest. DM stated when it was brought to the attention of the facility on 08/05/2024 by an anonymous reporter, it was reported to the Department as required. One staff interviewed stated Administrator was aware of the arrest but, no additional staff corroborated this. Therefore, it isn't possible to determine if the allegation occurred or not. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of all reports and appeal rights were provided and discussed with agency representative, John O'Brien.

Investigation Findings:
13Licensing Program Analysts (LPAs) Connie Goldie and Alyssa Burgess arrived at People's Care Administrative office located at N, Freeway Blvd Suite Sacramento, CA 95834 to deliver the findings of the above complaint investigation on 10/15/2024 at 02: PM as the facility currently does not have youth in placement. LPA Goldie spoke with John O'Brien, District Manager to discuss the findings of the complaint investigation and allegations stated above. LPA Goldie informed agency staff this case was investigated by Investigator Austin Blatnick, Badge 270 and Licensing Program Analyst Connie Goldie. The initial 10-day complaint investigation inspection at the facility was conducted by LPAs Connie Goldie and Brittany Crass on 08/06/2024. LPA obtained the following documentation: C1's Face Sheet, Behavior Service Plan, Individual Program Plan, T logs for July, Ther-app notes for July, Cash Resource Ledgers and Personal and Incidentals receipts for July 2024 and August 2024, Pleides House Rules, approved driver list, Staff telephone numbers and the facility sketch. Additional records received and reviewed include Sacramento Sheriff's Department police report and Axon body cam footage. Continued on LIC9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Connie Goldie 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PEOPLE'S CARE PLEIDESFACILITY NUMBER: VISIT DATE: 10/15/2024

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

met_with: John O'Brien, District Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/13/ Licensing Program Analyst (LPA) Rob Sandles conducted a case management inspection regarding a possible personal rights violation that occurred on 3/25/2021. LPA interviewed staff members and reviewed incident reports. A Technical Violation was issued. No further investigation needed at this time

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jesse Keller, Team Lead


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/31/21 at 11: AM and met with Kaymen Barnes, Facility Manager who assisted in the inspection. LPA observed that the home is licensed for two clients, one can be nonambulatory and each of the clients have their own bedrooms. LPA observed that the bedrooms are equipped with large beds and have adequate space for client belongings. The facility has two client bedrooms, two bathrooms - one is currently under construction and inaccessible until the work is completed. The front bathroom is equipped with a tub, toilet and sink and is appropriately stocked with paper towels, soap and bathing supplies for the clients living in the facility. LPA observed that the kitchen is equipped with the necessary supplies for food preparation for the clients in the facility and had the appropriate perishable and nonperishable supplies to meet client needs. LPA observed that the required postings were in the facility and included facility license, personal rights, complaint/grievance policy, CDSS Complaint Hotline, LPA observed that the facility had smoke and carbon monoxide detectors that were functioning as required.Fire extinguisher was observed to have been last inspected on 1/13/21. LPA observed that the facility appropriately stores medications, disinfectants and cleaning solutions where inaccessible to clients in the facility and not in the same location. First Aid Kit was observed to be fully stocked as required. LPA observed that the dining are was appropriate for the clients in care and had adequate seating for clients and staff. LPA observed that the back door was safe for client and observed to have a trampoline and safety net for client use. There is an office for privacy and confidential storage of facility records. LPA observed laundry Facilities that appear to be available for facility use but that clients are not capable of doing their own laundry so facility staff do that for them. LPA observed the facility van to have working lights all around, tires appeared to be in good working order. LPA observed that one seatbelt is over extended and does not retract. Facility reports that they do not allow residents to sit in that seat during transport until maintenance is completed. LPA observed that the facility does not maintain a Manual Restraint Log as required and did advise the facility that this is required and that this should start immediately. LPA observed that there is not appropriate documentation of the training for the Crisis Prevention Intervention (CPI) training that the facility uses for emergency interventions. LPA reviewed two staff files and did verify that individuals are criminally record cleared and associated to this location as required. LPA observed that the staff files had the appropriate documents as required. LPA reviewed two client files and observed that the client files were missing minor documents and did issues advisories as appropriate. LPA did cite the facility for not providing allowances to the clients in the facility. LPA also advised the facility on the use of the Psychotropic Medication Administration Record for the administration of psychotropic medications. LPA also advised the facility that they need to submit an Emergency Disaster Plan (per H&S Code 1565) by 1/31/2022 as well as the training for the staff that work in the facility. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 84365(d)(1) Emergency Intervention Staff Training. The facility does the required documentation related to the CPI training as required in this regulation for C2. Facility was cited for 84361(f) Documentation and Reporting Requirements in that the facility does not maintain a restraint log for client restraints as required by this regulation. Facility was cited for 84478(f) Responsibility for Providing Care and Supervision in that the facility is not providing an allowance for clients in care and clients are not receiving other monies from any other source (Personal and Incidental). LPA requested that the facility update the following documents within the next 30 days: LIC500, LIC 610C and LIC 308 and any other documents that need to be updated. An exit interview was conducted with Mr. Barnes and a copy of this report was provided.

Deficiencies:
84361(f): Documentation and Reporting Requirements

(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include

visit_type: Annual

met_with: Kaymen Barnes, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 11/30/22, at 12: PM,, Licensing Program Analysts (LPA), Connie Goldie, met with Program Administrator (PA) Pauletta Hendrix to conduct an unannounced Annual/ Required inspection of a single story, two bedroom, 2 bath home. At 12: PM, Staff Quinesha Silva DSP II greeted LPA Goldie and shared that Program Administrator is present. PA Hendrix stated that the current census was two clients. An Entrance Checklist was provided to the PA. Clients are both at school. LPA Goldie conducted the physical plant inspection with PA Hendrix. The tour began at 12: PM in the office. LPA observed license and Client registrar posted. A Foster Rights Poster will be provided to facility on next visit. LPA observed a spacious sitting room with adequate seating and lighting. We proceeded to the hallway, where LPA observed locked cabinetry containing individual containers for client's medications. A hole was observed in hallway 3 inches in diameter which PA stated was caused by a behavior on 11/28/22. Hygiene products were observed in individual spaces for each client- one in bedroom and one in bathroom based on client's preferences.The thermostat read 75 degrees within compliant range. The tour moved to bedroom one where a bed, dresser and night stand were observed to be compliant with a connected bathroom containing all supplies necessary-towels, soap and covered trash can. LPA observed mattresses on floor without bedframe in bedroom two. PA stated client has seizures and thus bed is placed on floor for safety. PA Hendrix stated a request for exception has not been submitted to licensing. LPA Goldie stated this a regulation violation.The tour moved to second bathroom which was also adequately supplied with towels, soap and hygiene supplies. Water temperature was measured and read a compliant 108 degrees. In the kitchen perishable food and non-perishables were adequate. Cleaning supplies and sharps were safely stored and inaccessible in locked cabinetry in the kitchen. The living room has adequate seating and lighting. LPA Goldie observed rug without skid material underneath which poses a safety risk. In the garage, a functional washer and dryer were observed. Fire extinguisher pin in place, smoke detector and fire alarms tested and compliant. Outside LPA Goldie observed broken glass on ground and a hole on the exterior of the house. All windows and screens were in good condition. continued on LIC812C. LPA Goldie completed Physical Plant and Operational Requirements domains and interviewed 1 staff member during today's inspection. The following Title Regulation citations were provided one Type A and two Type B violations were cited. Additionally four technical advisories and one technical violation were given, These are not deficiencies. Exit interview completed at PM. A copy of reports was discussed and provide to facility along with appeal rights.

met_with: Pauletta Hendrix Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 12/01//2022, at 10: AM, Licensing Program Analyst (LPA) Connie Goldie met with Program Administrator (PA) Pauletta Hendrix to continue unannounced/required Annual inspection. PA stated that two staff are currently in the facility. Both clients are at school. Additionally, Nelson Rivera Quality Assurance representative from People's Care is present conducting an audit. LPA Goldie completed the following inspection tool areas during today's inspection: Disaster preparedness Emergency Intervention Plan Staffing records Client records LPA Goldie interviewed two staff and two clients. Title B violations are being cited today. One civil penalty is being assessed for a repeat violation. 84361 (f) Documentation and Reporting Requirements. Technical Advisories are being given. These are not deficiencies. A exit interview was conducted with PA at 5: PM. A copy of reports along with appeal rights were discussed and provided to facility.

Deficiencies:
84361(f): Documentation and Reporting Requirements

(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include


summary: Facility Evaluation

raw_content:
Narrative:
On 01/26/2023, at time Licensing Program Analyst, (LPA) Connie Goldie made an unannounced plan of correction inspection to verify that POC has been corrected as facility failed to provide written documentation. During the inspection LPA Goldie met with Zahrod Griffin Vocational Nurse (VN). Both clients are at day program and two staff are present. LPA Goldie was informed that Pauletta Hendrix is no longer employed with Peoples Care Pleides effective Friday, 01/20/2023. Additionally, LPA Goldie was informed Kourtney Hamilton is the new Program Administrator formerly, the District Manager. During tour, LPA observed bedframe replaced and removal of rug. The cash resource log was reviewed for both clients and it was observed that clients are signing for cash disbursements and received allowance in November and December. LPA observed client's health screening is completed. Additionally restraint log was observed to be implemented. The POC's for these citations are cleared by visit. Kourtney Hamilton, Program Administrator, called at 12: PM and stated she was on her way and would provide access to staff records. Records provided indicated that staff evaluations are being conducted and placed in staff files. LVN Alexandria Pulido at Peoples Care Administration office verified physical and TB were completed for S3. LPA cleared all deficiencies by visit today. Exit interview completed at 12: PM with Administrator. A copy of the report along with appeal rights were left at the facility.

met_with: Zahrod Griffin Vocational Nurse Kourtney Hamilton Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/20/2023 at 1:00 p.m. a virtual case management meeting was held via MS Teams between Community Care Licensing, the Licensee and Alta Regional Center. Persons in attendance included: John O'Brien, Abe Avila, Chris Trevilla, Michelle Mainez, Kourtney Hamilton and Diane McGill from People's Care, Katie Robert, Heather Patrick, Jordan Eller, Rena Mathiesen and Jas Mann from Alta Regional Center, and Jodean Hall, Connie Goldie and Monica Roberts from Community Care Licensing. Topics discussed included: Non-Compliance Agreements from our Non Compliance Meeting on 5.9.2023, Status of Facilities' Compliance and Discussion and Problem Solving of Areas that remain out of compliance. Areas remaining out of compliance include: staffing, administrator in each home, ratios to meet IPP requirements, medication administration documentation, unauthorized psychotropic medication being used (Vape Pen). The following agreements were reached in regards to the above stated areas of concern: The facility uses several employment platforms such as LinkedIn, Dark Matter and Medical Professional, and provides hiring effort every two weeks. They are assessing internal staff for promotional opportunities for the administrator position and have several applicants waiting on fingerprint clearances. The facility will continue to assess applicants and keep CCL informed. The facility is now complying with IPP ratios and has received or is in the process of receiving revised IPPs for two clients in the Shawmutt and Kenneth locations decreasing the ratios needs. The facility has appointments scheduled with C1's psychiatrists and primary care provider to adjust C1's titration plan. During this meeting, CCL requested an updated summer activity schedule for each of the homes due by end of business 7/27/2023. End of report.

met_with: Licensee and Alta California Regional Center


summary: Facility Evaluation

raw_content:
Narrative:
On 08/01/2023, at 10:20 a.m., Licensing Program Analyst (LPA) Monica Roberts made an unannounced case management visit to follow up on the Non-Compliance plan (NCCP) provided to facility during Non-Compliance Conference meeting held on 05/09/2023. LPA Roberts was greeted by Danaye Hall, Lead Staff, and explained the reason for the visit. Ratio observed to be 3 staff to 2 clients. LPA Roberts conducted walk through of facility inside and out with the assistance of Danaye Hall. LPA observed two bedrooms and two bathrooms. Home was at a comfortable temperature of 70 degrees. Kitchen has at least 3 days of perishables and 7 days of non-perishables. Kitchen sink was broken this morning 8/1/2023 by a client. Administrator sent email confirming work order request to LPA. Living area has comfortable seating, a large bean bag, and a non-slip rug. All medications, sharps and toxins are locked. Outside, LPA observed locked shed and was granted access. Backyard was free of debris and has a comfortable patio set with functional chairs. LPA interviewed three staff, two clients and Administrator Hamilton. LPA obtained the following documents: Sign in sheets for staff trainings since 5/9/2023, P&I ledgers and receipts for both clients from 6/2023 and 7/2023 and the last two weeks of actual hours worked for July. Administrator stated C1's IPP draft was sent from Alta Service Coordinator via email on 7/31/2023. Administrator sent email confiming receipt of draft to LPA. No deficiencies were cited during today's inspection. A copy of today's report was provided and discussed with Administrator along with appeal rights. End of report.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/28/2023 at 9:45 a.m., Licensing Program Analyst (LPA) Monica Roberts made an unannounced Case Management Inspection for the purpose of obtaining documentation from 11/2021 to 11/2022. Staff present were: Samuel Martinez, Alijah Burton, and Quinisha Silva, Lead Staff. District Manager John O'Brien also arrived during the visit. LPA Roberts explained the reason for the visit and LPA was granted access to the home. A tour of the home was conducted. There is at least 3 days of perishable food and 7 days of non-perishable food. The home is a comfortable temperature of 69 degrees. The home and back yard are clean and clear of clutter. All chemicals and sharps are locked and out of client reach. No deficiencies were found in the physical plant inspection. LPA Roberts obtained medical documents for Youth 1(Y1) in the home from the time period requested. Documents included: Medical Administration Records (MARs) Medication count sheets, 15 minute medical checks, medical appointment records, Centrally Stored Medication & Destruction Records and July IPP. Quarterly reports were requested but unavailable. Exit interview conducted. A copy of this report was left with John O'Brien, District Manager.

met_with: Quinisha Silva, Lead Staff, John O'Brien, District Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/4/2023 at 2:00 p.m., Licensing Program Analyst (LPA) Monica Roberts made an unannounced Case Management Inspection for the purpose of obtaining records. Staff present were: Kamaree Burton and Quinisha Silva, Lead Staff. LPA Roberts explained the reason for the visit and LPA was granted access to the home. Staff member Jamie Hicks and Adiyana Hughes arrived shortly after. Adminstrator Kourtney Hamilton arrived at 3:00 p.m. A tour of the home was conducted upon arrival. There is at least 3 days of perishable food and 7 days of non-perishable food. The home is a comfortable temperature of 75 degrees. The home and back yard are clean and clear of clutter. All chemicals and sharps are locked and out of client reach. No deficiencies were found in the physical plant inspection. LPA requested the following documents to be reviewed and sent via email. 1. Incident reports and T-Logs from 10/2021, 2/2022 and 11/2022 2. Employment dates for former administrator Rodina Ventura 3. Most Current Behavior Report (9/2023) from People's Care Behaviorist 4. Contact for all staff of People's Care - Kenneth, Pleides and Shawmutt. Administrator Kourtney Hamilton provided contact list for staff at Pleides, and Current Behavior Logs (9/2023) from People's Care Behaviorist however the monthly summary for September 2023 was not on site. District Manager John O'Brien contacted behaviorist to obtain and forwarded to LPA. Incident reports and T-Logs from the requested months were not available on-site as Adminstrator is only allowed to access for 13 months back. Proof of this was provided. Therefore, John O'Brien, District Manager, emailed T-Logs to LPA from off-site, along with employment dates for Rodina Ventura (9/2020-10/2022) and contacts for all staff at Kenneth and Shawmutt homes. However, only 11/ Incident Reports were provided. Administrator will email LPA Incident reports from 10/2021 and 2/2022 by end of business on 10/5/23. Exit interview was conducted. A copy of this report was left with Kourtney Hamilton, Administrator.

met_with: Quinisha Silva, Lead Staff


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual inspection at the facility and met with Staff (S1) Alijah Burton, Staff (S2) Sam Martinez, Facility Manager (FM) Quinisha Silva, and Administrator Ashley Johnson, who assisted with the inspection. LPA conducted a walk-through of the facility and observed: Two client bedrooms, one dining area, two living rooms, two bathrooms, the garage, the kitchen, the staff office, the backyard, and front yard. All ramps/passageways were clear, the water temperature on one of the clients' bathrooms measured 109.6 degrees Fahrenheit which is within the required range of 105 to 120 degrees Fahrenheit. There was an adequate amount of perishable and non-perishable foods, which were stored correctly. One of the cabinet doors in the kitchen was broken. There was a Keurig coffee machine which delivered water that measured at 180 degrees Fahrenheit. There was a carbon monoxide detector in the house which was operable, and the two smoke detectors in the living room and dining area had their batteries popped out, making them ineffective. Staff popped the batteries back in during this inspection. The first aid kit was complete aside from missing tweezers. The clients' medications were locked. The emergency disaster plan posted in the office was out of date and had a staff on there who has not worked at the facility for some time. There was another emergency disaster plan posted in the living room which had that same staff, as well as multiple other staff that no longer work at the facility listed. The facility received an advisory note for this on 12/1/2022. During this inspection the Administrator updated the form. The written Emergency Disaster and Mass Casualty plan was missing descriptions of the facility's shut off valves and how to use them, provisions for emergency power, and provisions for managing medication, including refrigerated medications, in the event of an emergency. The Administrator updated the plan to meet requirements on this date. Training on this plan has not been completed as the plan was not complete, however the facility will be having an all staff training on 11/21/2023, in which all staff will be trained on this plan. The facility has an outstanding annual bill of $454, due as of yesterday. During this inspection, that was paid. The facility is conducting fire and other emergency drills as required. Board Minutes are available for review and show the Board providing oversight of the facility. One client has incontinence and is supplied diapers as necessary. LPA reviewed two client files and found: Both clients in this children's residential facility are non-minors. Non-minors are allowed to stay in children's residential facilities until their 21st birthday, however when 100% of the facility's population are adults, discussions about transition plans need to be had. LPA issued a Technical Assistance Advisory Note, which is not a citation, advising the facility to communicate with CCL about their plans to transition one or both of the clients to another facility, such as an Adult Residential Facility, the facility transition into an Adult Residential Facility, OR some other solution agreeable to the facility and CCL, for example. As of 11/9/2023, the facility has halted use of restraints on clients due to training needs and plans to utilize other forms of physical intervention, such as Ukeru pads. The facility is not attempting to assist clients with developing the skills necessary for self-sufficiency, listed under section 84478(c) of the regulations, to the point that they may be able to understand. While the clients may not be able to comprehend these concepts, the facility still should be making attempts to share the information with the clients. This can be documented in the quarterly reports (Needs and Services Plans) or annual reports. The facility administered one of the client's their afternoon medication early, when they got home at around 3: PM, but their medication was supposed to be given at 4: PM. FM explained that this is due to another medication being given to the client at 3: PM, and giving them to the client at the same time is less disruptive for the client. LPA and FM looked at the prescription and saw that the issuing time is 4: PM. LPA advised FM to contact the doctor to request to change it to 3: PM. LPA explained to FM that not following the times and still marking in the record that it was given at 4: PM, is inaccurate, and if changes need to be made for the benefit of the client, they need to take action to make the changes. FM called the doctor's office during this inspection, left a message, and emailed them as well. One client returned to the facility during LPA's inspection, however was having behaviors which were not conducive to LPA interviewing the client. LPA will interview the client on another date when they are in a better space. The other client returned to the facility later on. On this date the facility is being cited for violations of: California Code of Regulations, Tittle 22, Division 5, Section 80023(a); and the Non-Minor Dependent Interim Licensing Standards Sections 84470(b)(2)(F) and 84487(e)(2). LPA is issuing five technical violation advisory notes, which are not citations, for the following sections: 84468.3(f), 84478(c), HSC1565(d), HSC1565(b), and HSC1565(a), as well as two technical assistance advisory notes. LPA will return on another date to complete this inspection. An exit interview was conducted with FM and a copy of this report and appeal rights was left with her.

met_with: Quinisha Silva


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual continuation inspection at the facility and met with Facility Manager (FM) Quinisha Silva, and Administrator Ashley Johnson, who assisted with the inspection. LPA reviewed three staff files, the Facility Manager file, and the Administrator's file and found: All staff, facility managers, and Administrator are fingerprint cleared and associated to the facility as required. There is a staff schedule which is posted, however it was not fully accurate, and was missing staff titles, and time off. FM corrected this during the inspection. There are two qualified Facility Managers on the schedule currently, however there is no adequate Facility Manager coverage during night shifts, and sometimes during the weekend. One staff's CPR/1st Aid was expired by two days, however Administrator stated they have taken it, but the proof is in the staff's email, which they cannot yet access. CCL approved an exception request for Ashley Johnson on 11/8/2023 to temporarily act as Administrator over the Pleides house until FM Quinisha Silva can become the Administrator. The exception request was granted based on Ashley waiting to obtain the passed Administrator Certificate, as it just has not been issued yet. Upon further review of the requirements and files, neither Quinisha nor Ashley meet the education and experience requirements. LPA advised FM, Administrator, and District Manager (DM) John O'Brien that CCL will be discussing this matter and deciding the best way to move forward, working with the facility. New exception requests will likely need to be submitted. Files showed that a Behaviorist meets monthly with the two clients as required and the facility maintains records of their consultation hours and type of services provided as required. Staff are generally unaware of the Reasonable and Prudent Parent Standards (RPPS), and there is currently not an intentionally designated person per shift who will apply it to situations with the clients, per regulation. The Administrator is aware of RPPS, and when LPA explained what they are to FM, she knows what they are as well. FM stated this can be added to the all staff training being held on 11/21/2023. LPA also shared a link to more information about RPPS on the Department's website, with DM. LPA interviewed two clients and two staff. Based on interviews with clients, their needs are being met and they are being treated with dignity and respect. Based on interviews with staff, LPA found trainings on Mandated Reporting and the Emergency Intervention Plan need to be conducted to give staff a better understanding of them, otherwise, staff were knowledgeable about their job and the important aspects of the program. On this date the facility is being cited for a violation of the California Code of Regulations, Title 22, Division 5, Section 84065(d). LPA is also issuing three advisory notes, which are not citations. An exit interview was conducted with staff Osman Bangura and a copy of this report and appeal rights were sent to Administrator and Facility Manager, who had to leave before the inspection was complete.

Deficiencies:
84065(d): Personnel Requirements

(d) The licensee shall designate at least one facility manager to be present at the facility at all times when children are present

met_with: Quinisha Silva & Ashley Johnson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess conducted an unannounced case management inspection at the facility and met with Facility Manager (FM) Quinisha Silva, and Administrator Ashley Johnson, who assisted with this inspection. The purpose of this inspection is to assess an Enhanced Civil Penalty regarding licensed Group Home, People's Care Pleides (PCP). On 7/17/2023, LPA Monica Roberts and Licensing Program Manager (LPM) Jodean Hall delivered findings for the complaint investigation regarding the substantiated allegation that, "facility staff inappropriately medicated a client." On 12/12/2023, LPAs Burgess, Roberts, and Goldie, LPM Hall, and Regional Manager (RM) Margo Castaneda delivered an addendum to those findings to PCP, in-office. Over the course of the investigation, CCL found that the facility supplied marijuana, in the form of a THC vape pen, to a client under 21 years of age with an expired prescription, as well as permitted the client to use the vape pen exceeding the prescribed dosage. Additionally, CCL found that a former Administrator and staff simultaneously allowed the client dosing over what was prescribed and/or without a prescription in regard to the client's psychotropic medications, and that the Administrator procured additional psychotropic medications without the knowledge nor approval of the client's regular Psychiatrist. After consulting with our Department's Clinical Consultant, the case was evaluated and based on exhibited behaviors was determined to be a restraint, without a valid doctor's order to control the client's aggressive behaviors. On 7/17/2023 the facility was cited for a violation of the California Code of Regulations, Title 22, Division 6, Chapter 5, Section 84072(d), Personal Rights for this violation, which was then amended on 12/12/2023 and re-delivered to PCP. Based on confidential interviews and records review, the Department has determined that the Enhanced Civil Penalty is warranted for the physical abuse of a client in care by way of a chemical restraint, defined in Welfare & Institutions Code (WIC) 15610.63(f), while in the care of PCP. Health & Safety Code (HSC) 1548(f)(1)(C)(i): For a violation that the department determines constitutes physical abuse, as defined in paragraph (2), or resulted in serious bodily injury, as defined in Section 243 of the Penal Code, to a person receiving care at a therapeutic day services facility, community treatment facility, transitional shelter care facility, transitional housing placement provider, small family home, crisis nursery, group home, enhanced behavioral supports home licensed as a group home, group home for children with special health care needs, or short-term residential therapeutic program, the civil penalty shall be assessed as follows: (i) Two thousand five hundred dollars ($2,500) for a facility licensed to care for 40 or fewer children. On this date, the Department issuing an immediate Enhanced Civil Penalty of $2,500. An exit interview was conducted with FM and a copy of this report and appeal rights were provided


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with staff Kamaree Burton, Facility Manager Quinisha Silva, and Administrator Ashley Johnson, who assisted with the inspection. LPA reviewed client medications and Psychotropic Medication Administration Records (PMARs). Clients will be referred to as C1 and C2. LPA found: the facility's mail-order pharmacy sends bubble packs of pills to the facility around the middle of the month. However, the PMARs begin on the 1st of the month. There is no indication on the PMARs when a new bubble pack is started, and it is difficult to determine without staff's knowledge. LPA advised the facility to create a new PMAR anytime there is a new prescription number for the same medication. LPA also advised the facility to create a new PMAR when a new bubble pack is started, OR, clearly indicate on the PMAR the date the new bubble pack was started, and when it should end. See Confidential Names List: For C1, LPA found: Medication 1 (M1) had an incorrect prescription number in the PMAR; M2's prescription filled date is missing from the PMAR; M3 had an incorrect prescription number in the PMAR, however FM corrected it during the inspection. For M4 and M5, PMAR is missing Quantity Prescribed, Prescription Filled Date, # of Refills. For M6, the pills were split from the original box into two different boxes noted as AM and PM. The other box was just an old pill box with an old label. When LPA counted M6, there were 30 pills, and a full box is 60 pills. LPA asked FM what date did C2 start the pills. FM stated 1/11/2024. All time slots were marked as taken for M6, with none missed or refused. By that count, there would be a surplus of 14 pills. Later, FM found that it actually started on 1/19/2024, and the counts added up. LPA explained to FM that this is a good example to show the importance of creating a new PMAR when a new box is opened. LPA found the dosage for M7 in the bubble packs was twice than what was in the PMARs for M7. The PMARs stated M7 200MG is the dosage per two tablets, which are taken twice daily. However it should have been 400MG per two tablets, twice daily, for a total of 800MG/daily. FM called the Pharmacy to confirm the right medication was in the bubble packs, and the pharmacy confirmed. FM corrected the PMAR on this date to reflect the correct dosage. Additionally, the 5PM initial space for staff to indicate medication was issued, was blank for 2/1/2024 for M7, even though the medication was given. FM stated this was due to not including the 5PM time slot on the PMAR initially, so staff did not know to initial there. This was corrected on the PMAR. Beyond this medication review, CCL also received an incident report from the facility dated 12/28/2023, which details the following medication errors: 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. To prevent delays in getting refills, the facility will be switching over to a different pharmacy which can better serve their needs. LPA was unable to complete the inspection on this date, due to the time. LPA will return on a later date to complete the inspection. An exit interview was conducted with Admin and FM and a copy of this report and confidential names lists were provided to them.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst Michelle Kyane and Licensing Program Manager Stephen Kim conducted a case management inspection on 05/03/2023 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 4 out of Direct Care Staff and 2 out of 2 youth files were reviewed. 3 out of Direct Care Staff and 0 out of 2 youth were interviewed. (See the Confidential Names List, LIC 811, dated Month Day, Year). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Kyane and LPM Kim observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to the Facility District Manager John O'Brien and the Facility Administrator Quinisha Silva.


summary: Facility Evaluation

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Narrative:
On 05/08/2024, at 2: PM, Regional Manager, Margo Castaneda, Licensing Program Manager (LPM) Jodean Hall, Licensing Program Analysts' (LPA's) Connie Goldie, and Alyssa Burgess conducted a Non-Compliance Review Meeting via Teams. Present from Peoples Care is: John O'Brien, NorCal District Manager, Michelle Mainez, Chief Operating Officer, Diane McGill, Program Administrator, and Quinisha Silva, Program Administrator. Present from Alta Regional Center is: Toby Golden, Client Services Manager. The purpose of the office meeting is to review the current status of Non-Compliance plan. The following NCC primary areas of concern were reviewed: supervision, staff to child ratio, training, reporting requirements, vape pen and board accountability. It was acknowledged that Peoples Care Quality Assurance created and implemented a training program and have continued to conduct ongoing training as requested. Incident reporting has increased. The compliance for each location: People's Care Shawmutt, People's Care Kenneth, and People's Care Pleides was reviewed for the time period of May 2023- May 2024. The following current existing concerns were discussed: staffing to meet the needs of clients in care, not utilizing the emergency intervention plan as identified in facility's plan of operation when required and board accountability. Based on record reviews, the Shawmutt and Pleides locations have not had one complaint opened in the last 12 months and the citations issued have decreased. As a result, these locations will be removed from the non-compliance plan. The Kenneth location has had increased complaints and increased citations and will remain on the NCC for an additional six months. Increased oversight will remain in effect through 11/08/2024. Continued on LIC809C The Department requests a revision of the Emergency Intervention plan be submitted within thirty days with clear directives on each of the different techniques and when they will be utilized along with the verification that staff have been trained on the use of the techniques outlined based on defined behaviors. An Administrator Exception Request needs to be submitted to the Department immediately. A copy of this report was provided via email to John O'Brien, District Manager for signature.

met_with: John O'Brien District Manager


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility regarding a medication error reported to CCL on 5/23/2024. Present during this inspection was LVN Alex Jenkins and Administrator Diane McGill, who assisted LPA with the inspection. LVN was training new nursing staff Lillian Hull during this inspection. The incident report dated 5/23/2024 stated that one client, C1 (see Confidential Names List dated 5/31/2024), had been in the hospital from 4/28/2024 to 5/3/2024, returning with new medications that were to start on 5/7/2024. On the 7th, LVN and QA Specialist conducted a full medication audit. After the aduit, Administrator Quinisha Silva was instructed to create new Medication Administration Records (MARs) and to remove the old medication and put it in the destruction box for destruction. Admin affirmed this was understood. All old medications were placed in the destruction box and new MARs were created, with the exception of one medication, M1. Due to this, C1 was given both the old and new doses of M1 from 5/7/2024 - 5/21/2024, 15 additional doses. Once this was discovered, C1 was evaluated at the hospital for observation, with no issues. LVN audited the medications once again on 5/22/2024. An interview was conducted with Admin on 5/29/2024 regarding this incident. During that interview LPA was informed that it was Admin's mistake not to have removed the medication, however C1 was only given the extra doses of M1 for a maximum of four days. Admin had instructed the staff to put the old medication at the bottom of the medication cabinet, and to not give it out to C1. LPA requested the M MAR that was supposed to have been removed, and the new one, however when LVN looked for them, they appeared to have gone missing from where she put them in the binder. LVN believed it was likely destroyed. LPA observed the medication destruction area and found there to be a chemical solution in which the staff put the medications to dissolve, and another trunk where meds will sometimes go to be later destroyed in the bottom area of the medication cabinet. LPA reviewed C1's medications and MARs together with LVN. LPA found for M2 for MAR 5/2024, 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. 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. 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. After review it appears it might be an error on the pharmacy's initial count, however that is not certain. 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. LVN called the pharmacy and found the pharmacy did make an error. The pharmacy asked LVN to check the rest and call back so any others can be corrected too. When LPA and LVN were done with the medication review, the pharmacy was out to lunch. When LPA returns to complete this case management, LVN will have obtained the corrected MARs and will have them, clearly understandable, at the facility for LPA's review. 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. CSMDR stated M6 was filled on 5/22/2024 60 pills (1 taken twice daily), MAR stated began 5/23/2024. There were 43 left, and 17 taken, which was accurate. 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. For M8, it was filled on 5/22/2024, it was started on 5/23/2024. There were 28 left, and 16 given, so they added up accurately. M9 was accurate. M10 is a PRN. LPA collected copies of MARs and CSMDRs. After conferring with LPA's supervisor, LPA will be returning on a later date to address the multiple medication errors found during this inspection, and the medication error of the incident report for which the case management was started. Administrator and LVN conducted a medication training, which was pre-scheduled, with all staff during this inspection. Administrator and LVN expressed the severe importance of medication accuracy. An exit interview was conducted with Administrator and a copy of this report was provided to her.

met_with: Diane McGill


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced Case Management inspection at the facility and met with Administrator Diane McGill, who assisted with the inspection. Nurse Lilian Hull was conducting a medication audit at the time of inspection. LPA and Nurse reviewed the medications together. All medications were accurate, documentation was accurate, and no deficiencies observed. An exit interview was conducted with Administrator and a copy of this report was provided to her.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced annual inspection at the facility and met with Administrator Diane McGill, who assisted with the inspection. LPA conducted a walk-through of the home with Administrator and observed: The house has no clients in placement and no staff assigned to work at this house. The agency is not planning on accepting any placements at this time. LPA observed some trash and clutter around the house and advises the facility to clean the house. LPA observed client bedrooms, living room, dining room, kitchen, staff office, and outdoor space. The home was in a safe and sanitary condition. The smoke detector in the hallway was low on battery and was beeping. The carbon monoxide detector originally had its battery popped out. Admin popped the battery back in and it was functional. The agency is conducting board meetings on at least a quarterly basis and discussing the required topics. The facility does maintain CCL records at the facility in a binder. Visits conducted on 10/15/2024 and all visits in 2021 were not present in the binder, however Administrator was able to attain these documents during the inspection. Administrator will print them out and maintain them in the binder at the facility. LPA provided some of the documents that were missing. No citations are being issued on this date. LPA issued Advisory Notes, which are not citations, to address some areas in need of correction. An exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to her.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess and Licensing Program Manager (LPM) Jodean Hall met virtually with Regional Director (RD) Mauricio Villatoro and VP of Quality Assurance (VPQA) Serena Rojas, and Quality Assurance Staff (QA) Gina Renteria to discuss the Legal Stipulation and Waiver, and Order (SWO) regarding the facility's probation, effective 12/31/2024. RD, VPQA, and QA acknowledged their receipt of the SWO, and that they have reviewed it. LPA reviewed the agreed upon conditions of the SWO with RD, VPQA, and QA to ensure their understanding of it. VPQA stated they have completed the first round of quarterly trainings required by the SWO, has the SWO posted in a common area of the facility, they have conducted weekly check-ins at the facility completed by QA, and a list of associations have been provided to CCL as well as training records. An Administrator from one of People's Care's Adult Residential Facilities is in the process of becoming the Administrator of this facility. The period of probation is three years. Any period of time the facility is non-operational during this probationary period, that time will be added to the length of probation. As of this date, during the probationary period, the facility has been non-operational since 12/31/2024. The facility is not sure at this time when they will become operational. LPM advised VPQA to verify with the Regional Center if they will place with them during the probationary period. An exit interview was conducted with RD, VPQA, and QA and a copy of this report was provided to them. They will send this report back with their signature on it for the file by COB today.

met_with: Mauricio Villatoro, Serena Rojas, Gina Renteria


summary: Facility Evaluation

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Narrative:
On 01/26/2023, Licensing Program Analyst, LPA, Connie Goldie made an unannounced case management visit at 12: PM. LPA Goldie met with Zharod Griffin, Vocational Nurse (VN) to assist with this visit. 2 staff are present and the clients are both at day programs. LPA Goldie toured the facility with VN Griffin. LPA Goldie observed a single story, two individual bedrooms with bed, dresser and closets, two bathrooms with soap and towels, kitchen with perishables and non-perishables as required. In kitchen LPA observed unsecured cabinet with chemicals-bleach and cleaning products. LPA clarified that it was unlocked and VN stated yes. LPA toured dining area with adequate seating , living room and family room with appropriate lighting. Temperature was a comfortable 72 degrees. Outside was clear of debris. Shed was observed to have a combination lock and was unable to be opened thus inaccessible to LPA. Two citations are being issued today . Title Division Chapter Buildings and Grounds 80087 (g) and Health & Safety Code 1533. Exit interview was conducted at 2: PM with Administrator Hamilton. A copy of this report along with appeal rights was provided to the facility.

met_with: Zharod Griffin Vocational Nurse Kourtney Hamilton Administrator


summary: Facility Evaluation

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Narrative:
On 3/16/2023, LPAs Monica Roberts and Connie Goldie conducted an unannounced case management inspection at Pleides Avenue with the purpose being to follow up on deficiencies given during the home's annual inspection in November 2022. LPAs met with Adminstrator Kourtney Hamilton and explained the reason for the visit. LPA Roberts requested the PMAR for both clients and reviewed. LPAs followed up on alarm work order to ensure resolution. LPA Goldie completed facility file review and determined that restraint log was implemented per regulation. LIC500 was reviewed and all staff are associated. P&I log was reviewed for both clients and observed allowances have been given in January and February 2023. Administrator was given conflicting information in March regarding allowance therefore LPA Goldie confiirmed with Compliance Director Chris Trevilla and going forward clarity has been established that clients will still receive allowance monthly. Employee Monthly Trainings have been done bi-weekly. Employee performance evaluations have not been completed. First Aid Kit was observed to be missing a manual. LPAs completed a walk through of the home, inside and out. LPAs observed the kitchen to have adequate amounts of both perishable and non-perishable foods. All sharps and chemicals were locked. Bedrooms, laundry facility and living spaces were clean and organized. Client #2 received a new dresser however it was the wrong size therefore a new work order was placed today for a sufficient dresser. Upon walking outside, LPAs observed swampy, flooded areas and a fence partition of 25 foot length that has fallen in the right back corner of the back yard. LPAs completed two employee file reviews. Two Title Division Chapter Citations and one repeat Civil Penalty are being cited. Additionally one Technical Advisory was given. Exit interview was completed.

met_with: Kourtney Hamilton, Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts Monica Roberts and Tamara Hill made an unannounced case management inspection on 8/17/2023 at 11:15 a.m. and met with Kourtney Hamilton, Administrator to discuss a previous inspection report erroneously provided to the facility on 7/17/2023. This report was provided to the facility as a complaint investigation report when this inspection should have been a case management. During the course of the complaint investigation #23-CR-20230215111337, LPA observed deficiencies during a physical plant inspection of the facility. A description of those observations are as follows: On 6/2/2023, two client IPPs were reviewed with the administrator. Client #1's IPP dated July 2022 states "When Connor first moved to the care home he had 1 to 1 support but due to his aggressive behavior he was put on Health and Safety Waiver and currently has 2 to 1 support." Upon LPA's arrival to the home on this date, there was only one staff present, instead of the required three staff. As a result of this observation, facility was cited for violation of California Code of Regulations, Title Division 6, Chapter 5, Regulation 84065.5(c): Staff Child Ratios. Record review and administrator's statement confirm that current IPP does not match the staffing that is in place in the home. On 6/2/2023, during the home inspection, an unsecured kitchen knife was discovered in a kitchen drawer. Program RN Zahrad Griffin secured the knife in the sharps container during LPA's visit. As a result of this observation, facility was also cited for the following violation of California Code of Regulations, Title 22, Division 6, Chapter 1. Article Physical Environment Buildings and Grounds (g) (1). Statement from RN confirms that knife was left in the silverware drawer unsecured. Due to these observations and deficiencies being erroneously provided on incorrect documents on 7/17/2023, the documentation and deficiencies are being reissued today, 8/17/2023 and have been cleared today. Exit interview was conducted. A copy of this report and appeal rights were left at the facility. End of report.


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts Monica Roberts and Tamara Hill made an unannounced plan of correction inspection on 8/17/2023 at 11:12 am and met with Kourtney Hamilton, Administrator. During this inspection, LPAs requested August 2023 medication administration records (MARs) and psychotropic medication records (PMARs) for C1 (see LIC811 dated 8/17/2023), reviewed medications for August 2023 and requested copies of the PMARs and MARs for C1 as a result of complaint inspection conducted on 7/17/2023 where the facility was cited for medication issues related to children's records. LPAs Roberts and Hill reviewed medication records and observed that the medication orders are coming from the pharmacy and there are documents indicating all the required elements except the minimum number of hours between doses. Title 22, Health Related Services section 80075(b)(6)(D)(3) requires signed, dated written order(s) from a physician on a prescription blank that specifies all of the following in that order: * The specific symptoms which indicate the need for the the use of the medication; * The exact dosage; * The minimum number of hours between doses; * The maximum number of doses allowed in each 24-hour period. LPAs observed that the facility did not have the minimum number of hours between doses documented. As a result of the observations made during the inspection on 8/17/2023, the facility was cited for Health Related Services section 80075(b)(6)(D)(3). In addition, during today's inspection, a signature was obtained on a 7/17/2023 complaint inspection report that had no electronic signature. Exit interview was conducted and documents were provided to Ms. Hamilton along with appeal rights.


summary: Facility Evaluation

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Narrative:
On 9/21/2023 at 9:35 a.m., Licensing Program Analysts (LPA) Monica Roberts and Tammy Hill made an unannounced Case Management Inspection for the purpose of reviewing medication records. Staff present were: Samuel Martinez, Alijah Burton, and Quinisha Silva, Lead Staff. LPA Roberts explained the reason for the visit and LPAs were granted access to the home. A tour of the home was conducted. There is at least 3 days of perishable food and 7 days of non-perishable food. The home is a comfortable temperature of 75 degrees. The home and back yard are clean and clear of clutter. All chemicals and sharps are locked and out of client reach. No deficiencies were found in the physical plant inspection. Upon review of the medications and client medical records (MAR), prescription numbers on the bubble pack did not match the MAR for 4 out of 10 of Client 1's medications. For Client 2, 3 out of 9 prescription numbers on the bubble pack did not match the MAR. Facility was cited for Health Related Services: 80075(b)(6)(d). Exit interview was conducted with Quinisha Silva, Lead Staff and Kourtney Hamilton, Administrator (via phone). A copy of this report and appeal rights were left at the facility. End of report.


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPA) Alyssa Burgess, Monica Robert, and Connie Goldie, Licensing Program Manager (LPM) Jodean Hall, and Regional Manager (RM) Margo Castaneda, conducted an office meeting located at Goethe Road, Suite 100, Sacramento, CA 95827 to discuss additional findings revealed during the complaint investigation dated 2/15/2023, #23-CR-20230215111337. Present from People's Care was: John O'Brien - District Manager, Michelle Mainez - Cheif Operating Officer, Ashley Johnson - Interim Administrator, Quinisha Silva - Facility Manager, and Diane McGill - Administrator. Subsequent to the findings made on 7/17/2023, CCL received additional information. LPAs received facility T-Logs, Psychotropic Medication Administration Records (PMARs), Quarterly Reports, Behavior Consultant data, Staff Data Reports, Data Tracking Sheets, and another Facility Incident Report. Dates for this data provided was sporadic and varied due to admitted and observed record keeping failures by the facility. Based on the records reviewed, LPAs found many reportable incidents which were not reported to CCL as required. Due to the facility's insufficient record keeping, the following is only a partial summary. Incident Reports were not received: For client C1 (see confidential names list), in August 2022, an incident involving C1's physical aggression and property destruction. In September 2022, C1 was physically restrained due due physical aggression towards staff. In October of 2022, C1 was physically restrained for hitting another client. On 12/17/2022, C1 was placed on a 5150 hold. On 11/20/2022, C1 had escalated behaviors, including self-injurious behaviors (SIB) for close to six hours. In February 2022, the Staff Data Report shows there were 87 incidents of, "Property Destruction," "Self-Injury," and "Aggression," from C1, however no incident reports were received in the month of February 2022. In January 2022 on the Data Tracking Sheets, for C1, there were five incidents of SIB, three incidents of property destruction, and five incidents of aggression noted, however none of these incidents were reported to CCL. In February 2022 on the Data Tracking Sheets, for C1, there were 27 incidents of SIB, 18 incidents of property destruction, and 43 incidents of aggression noted, however, none of these incidents were reported to CCL. In March 2022 on the Data Tracking Sheets, for C1, there was one incident of SIB, three incidents of property destruction, and 15 incidents of aggression noted, however, none of these incidents were reported to CCL. In the Updated Summary of C1's Quarterly Report, there was one instance of high-intensity problem behavior; C1 gained access to the staff office, broke the TV off of the wall, and kicked a hole in the bathroom door. This incident was not reported to CCL. On this date the facility is receiving a citation for the violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Reporting Requirements, Section 80061(b)(1)(E), detailed on the D-Page. LPM and LPAs also discussed with People's Care the current Administrators' qualifications and exception requests for Kenneth and Pleides houses. LPM informed People's Care that CCL will approve the exception requests for Ashley Johnson (Kenneth) and Quinisha Silva (Pleides) for one year, with the condition that both will pursue a continuation of education to work towards meeting the regulatory requirements. An exit interview was conducted with all present, and a copy of this report, confidential names list, and appeal rights were issued to John O'Brien.

met_with: People's Care Management


summary: Facility Evaluation

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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 medication errors, and met with Facility Manager Quinisha Silva. Please refer to that LIC809 dated 2/2/2024 for a summary of inspection findings. On this date, the facility is being cited for violations of the California Code of Regulations, Title 22, 1. 80075(k)(6): Health Related Services. The following requirements shall apply to medications which are centrally stored: Each client's medication shall be stored in its originally received container (for medication M6 - see confidential names list dated 2/2/2024). 2. 84070(b)(13): Children's Records. A separate log for each psychotropic medication prescribed to the child documenting all the following: - (B) The date of the prescription - (for medications M2, M4, and M5). - (C) The quantity of medication and number of refills initially prescribed (for medications M4 and M5). - (E) The prescribed dosage and directions for use as specified in writing by the physician prescribing the medication, including any changes directed by the physician (for M7). - (H) Staff initials for each time a psychotropic medication is taken by a child, as an indication that they supervised the child self-administering their psychotropic medication (for M7). Section 84070(b)(13) is a repeat deficiency within 12 months and a Repeat Violation Civil Penalty is being issued in the amount of $250. This deficiency was corrected during this inspection. LPA reviewed the Centrally Stored Medication and Destruction Records for C1's correct medications, and all prescription numbers match the current medications. On 2/2/ LPA found that two of C1's medications had incorrect prescription numbers on the Psychotropic Medication Administration Records (M1 & M3). LPA is writing an advisory note, which is not a citation, for these errors. An exit interview was conducted with Facility Manager and a copy of this report, medication confidential names list, and appeal rights were provided to her.