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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606176
Report Date: 10/01/2021
Date Signed: 10/01/2021 01:51:01 PM

Document Has Been Signed on 10/01/2021 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KATHYANN HOME INC.FACILITY NUMBER:
197606176
ADMINISTRATOR:LA SEAN JAMESFACILITY TYPE:
735
ADDRESS:11906 KATHYANN STREETTELEPHONE:
(818) 201-7225
CITY:LAKEVIEW TERRACESTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 3DATE:
10/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:La Sean James TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an case management, regarding an incident report that was submitted to Licensing, alleging staff # 1 (S1) physically abused client # 1 (C1). LPA arrived to the facility at 945am and was greeted by staff. Staff allowed LPA to enter the facility, and completed COVID screening with temperature check and requesting LPA to sign in the visitors book. LPA informed staff the reason of the visit. Staff contacted Co-Administrator Louise McMillon, who LPA spoke to and also informed her her the reason of the visit. Staff also contacted Administrator LaSean James, who arrived shortly after.

During today's visit, LPA conducted interviews and reviewed facility and client documents. It was revealed, a client stole a lighter from staff. Staff did not report it to the Administrator in a timely manner, and Administrator did not submit an special incident report (SIR) to Licensing. According to the Administrator, she did not become aware of the incident, until it was revealed from the incident that recently occurred with S1 and C1, on 09/17/2021. LPA also became aware of another incident with another client, back in July 2021, for destruction of property, a SIR was not submitted to Licensing, but was reported to North Los Angeles County Regional Center (NLACRC). After conducting interviews and reviewing documents pertaining to the incident of alleged physical abuse, LPA has determined that further action is needed to complete the investigation of alleged physical abuse. Due to the facility not reporting and submitting SIRs to Licensing regarding previous incidents, a citation will be issued, due to failure to report. At this time, further review is needed.

Exit interview, citation issued, appeals rights, and copy of report provided to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2021 01:51 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 10/01/2021 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KATHYANN HOME INC.
FACILITY NUMBER: 197606176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
80061(b)

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Reporting Requirements; (b) Upon the occurrence...any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day... in addition, a written report
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Administrator will submit the SIR pertaining to the incident that occurred with C1, having a lighter at the facility. And will ensure that all incidents pertaining to the facility, a SIR will be submitted in a timely
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submitted to the licensing agency within seven days..This requirement was not met, evidenced by the Administrator confirmed a SIR was not submitted to Licensing regarding an incident with C1 and having a lighter.
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manner.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021


LIC809 (FAS) - (06/04)
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