191800884-2-12-2025-11-AS-SCIS-DGGUD7-20250508152858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191800884
Report Date: 02/12/2025
Date Signed: 02/12/2025 12:17:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2025 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250204092301

FACILITY NAME:	WILLING WORKERS, INCORPORATED		FACILITY NUMBER:	191800884
ADMINISTRATOR:	WENDY CARROLL LANIER		FACILITY TYPE:	775
ADDRESS:	4813 W WASHINGTON BLVD		TELEPHONE:	(323) 937-5950
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90016
CAPACITY:	240; 240	CENSUS: 65	DATE:	02/12/2025
		UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Ronald Revere Program Dir		TIME COMPLETED:	12:18 PM

ALLEGATION(S):

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Staff did not properly report an incident involving a client.
Client sustained multiple injuries while in care.

INVESTIGATION FINDINGS:

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On 02/12/25, the department conducted a subsequent unannounced complaint visit to further investigate the above-mentioned allegations and deliver findings. The department met with Program Director, Ronald Revere, and explained the purpose of today’s visit.

The investigation consisted of the following: On 02/10/25, the department reviewed client files, requested, and received the following documents: staff roster, client roster, and copies of Serious Injury Report (SIR) dated: 01/31/25, Physician Report, Client Development Evaluation Report, South Central Regional Center Individual Program Plan, Client Daily Notes, and Client Body Check form for C1. Additionally, the department conducted interviews with staff #1-#6 (S1-S6) clients #1-#6 (C1-C6) and witness #1-#2 (W1-W2).

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250204092301

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WILLING WORKERS, INCORPORATED	FACILITY NUMBER: 191800884
	VISIT DATE: 02/12/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not properly report an incident involving a resident. It is alleged that the above-named facility did not report an incident involving a client fall and/or injury to their provider and/or guardian. On 02/10/25, the department interviewed S1-S6. Based on interviews conducted, 4 out of 6 staff interviewed stated that they don’t know if C1s provider and/or guardian was notified regarding C1 falling on 01/31/25. 6 out of 6 staff interviewed stated that the client’s provider and/or guardian along with all applicable agencies are notified when a client falls, has an accident, and or sustains an injury.6 out of 6 staff interviewed stated that an SIR was submitted to the department on 01/31/25.

Based on interviews conducted 3 out of 6 clients interviewed revealed that they do not know if staff reported an incident involving a client falling and/or an injury to their provider and/or guardian. 3 out of 6 clients were unable to communicate with the department.

A review of records revealed that an SIR dated 01/31/25 was provided to the department revealing that a client fell during a fire drill on 01/31/25.

Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. 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.

Allegation: Client sustained unexplained injuries while in care. It is alleged that a client was taken to urgent care and was treated for head, neck fracture, and bruising to their arm. Based on interviews conducted, 5 out of 6 staff interviewed stated that C1 did not have any visible injuries. An interview conducted with C1’s coach S4 revealed that immediately after they noticed that C1 had fallen, they rushed to their aid. S4 stated that they did a body check and did not see any visible injuries on C1 that would require emergency services and/or first aid. S4 stated they also asked C1 if they were ok, to which C1 stated they were.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250204092301

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: WILLING WORKERS, INCORPORATED	FACILITY NUMBER: 191800884
	VISIT DATE: 02/12/2025

NARRATIVE

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Based on interviews conducted, 3 out 6 clients interviewed revealed that they did not know if C1 fell on 01/31/25, and 2 out of 6 clients interviewed were unable to communicate with the department. 3 out of 6 clients interviewed revealed that they do not know if C1 sustained any injuries while in care, and 3 out of 6 clients interviewed were unable to communicate with the department.

A review of records revealed that it was noted on C1s Daily Notes that C1 had fallen on 01/31/25 during a fire drill. The department reviewed C1s Body Check form and it revealed that a body check was done on C1 in the AM and PM. The department did not observe any notes stating that C1 had any injuries on 01/31/25.

Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. 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 Program Director, Ronald Revere, and a copy of the report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC9099 (FAS) - (06/04)

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