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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608108
Report Date: 07/03/2024
Date Signed: 07/03/2024 03:31:18 PM


Document Has Been Signed on 07/03/2024 03:31 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ALEMOH FAMILY HOMEFACILITY NUMBER:
197608108
ADMINISTRATOR:BABATUNDE ALEMOHFACILITY TYPE:
735
ADDRESS:10714 KURT STREETTELEPHONE:
(818) 899-5354
CITY:LAKEVIEW TERRACESTATE: CAZIP CODE:
91342
CAPACITY:4CENSUS: 3DATE:
07/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Babatunde Alemoh - AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On this date a Non-Compliance conference was conducted at the Woodland Hills South Adult and Senior Care Regional Office. Licensee, Babatunde Alemoh was in attendance.

On 2/2/24, Licensing Program Managers (LPM)s Troy Agard and Nichelle Gillyard initiated a complaint investigation for an allegation of physical abuse, specifically “Facility staff physically assaulted a resident causing bruising” on 1/28/24. The LPMs met with the Administrator Designee, Babatunde Omotayo (S3).

During the visit on 2/2/24, the LPMs requested documents pertinent to the investigation, including but not limited to the facility staff files for Staff #1 (S1) and Staff #2 (S2). The documents provided included documentation of training by the Crisis Prevention Institute (CPI) for S1 and S2. The documents stated that S1 and S2 attended the training on 8/11/23 for a period of 5 hours. During the investigation CPI was contacted to verify the training documented. The representative from CPI denied that the training had been provided to S1 or S2 on 8/11/23. S3 also stated that neither S1 nor S2 had been present in the facility on 1/28/24.

The Community Care Licensing (CCL) Investigations Bureau (IB) Investigator Jose Santana was assigned to investigate the complaint. On 3/11/24, IB Santana submitted the completed investigation that deemed the allegation of physical abuse to be Substantiated and identified the abuser at S1.

On 2/6/24 IB Santana conducted an interview with S3. During the interview S3 provided false statements when identifying the staff on duty. S3 stated that S2 and S4 were the staff on duty on 1/28/24. S3 stated that he restrained the client himself with no resulting injury. S3 stated that S1 did not work that day but did visit for approximately 15-20 minutes but was not working.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALEMOH FAMILY HOME
FACILITY NUMBER: 197608108
VISIT DATE: 07/03/2024
NARRATIVE
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(continued from LIC 9099)

On 2/14/24 IB Santana conducted an interview with Babatunde Alemoh (Licensee). Licensee stated that S4 had not advised him of the incident on 1/28/24. Licensee stated that neither S1 nor S2 work at the facility. Licensee initially stated that S1 was not at the facility on 1/28/24 but later conceded S1 was there. Licensee had submitted an Incident report that documented that he was the father of the staff member on duty on 1/28/24 but later re-submitted a revised version of the document removing any mention of his son(s) being present.

On 2/11/24 IB Santana conducted an interview with S4. S4 initially stated he was working on 1/28/24 but then denied having been present at the facility on 1/28/24 and indicated that S3 had instructed him to provide false information.

Based on the information obtained during the investigation it is determined that in an effort to mislead the investigator and obstruct the investigation, the Licensee, S1 and S3 provided false claims throughout the investigation and provided falsified documents of training by CPI.

Citations issued, appeal rights provided and copy of the licensing report provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/03/2024 03:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ALEMOH FAMILY HOME
FACILITY NUMBER: 197608108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2024
Section Cited
HSC
1550(c)

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(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home.

This requirement is not met as evidenced by:
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The administrator stated that there is no client at the facility at this time, but will send all staff to retrain on CPI and will provide copy to CCL on or before the POC date.
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Based on record review, the licensee failed to ensure that the staff was properly trained and properly documented on a required training on Level 4 facility. This poses an immediate health and safety risk to the residents in care.
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Type B
07/12/2024
Section Cited
CCR80012(a)

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(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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The administrator stated that there is no client at the facility at this time but will retrain staff and self on writing Unusual Incident Report (LIC 624) and mandated reporting and will submit a proof of training to CCL on or before the POC date
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Based on interview, licensee failed to provide accurate information to the CCL regarding staff on duty which is tantamount to providing false information. This poses a potential health and safety and personal rights risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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