197609322-8-17-2023-31-AS-NGID-CW4URL-20230928154853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609322
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:48:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2023 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20230811111954

FACILITY NAME:	WILLOUBEE RESIDENTIAL II		FACILITY NUMBER:	197609322
ADMINISTRATOR:	WILLOUGHBY, MARCUS A		FACILITY TYPE:	735
ADDRESS:	3123 EMERALD LN		TELEPHONE:	(661) 992-7699
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 4	DATE:	08/17/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jessica Hernandez, Channel Williams		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff failed to treat resident with dignity and respect
Staff confiscated resident’s personal belongings
Staff violated resident’s personal rights
Staff failed to meet resident’s grooming needs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angela Panushkina, Christopher Alemoh and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPAs met with the administrator, Jessica Hernandez, and staff, Channel Williams and advised them of the complaint. Today's investigation consisted of interviews with residents, administrator and staff. LPAs also conducted a record review and a physical plant inspection. The facility is a one story building. It is a level IV home with private rooms for all four clients in care.

Staff failed to treat resident with dignity and respect:
In regards to the allegation, it was reported that staff has been grabbing and pulling Resident 1's (R1) legs, pulling R1 out of bed. No witnesses and dates were given to this report to corroborate the allegation. Interviews made with the administrator and staff also do not corroborate with the allegation. Interview with R1 also could not confirm any witnesses, date and time. Furthermore, three (3) of the three (3) residents

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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 31-AS-20230811111954

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL II	FACILITY NUMBER: 197609322
	VISIT DATE: 08/17/2023

NARRATIVE

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have never witnessed staff mishandling R1. Based on the information obtained, there was insufficient evidence to prove that staff failed to treat resident with dignity and respect. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff confiscated resident’s personal belongings:
In regards to the allegation, it was reported that staff confiscated R1's cell phone, DMV book and miscellaneous paperwork, and threw R1's DMV book away. Interview with R1 could not confirm who confiscated their belongings and threw their DMV book away. R1 could not identify staff or any witnesses to corroborate the allegation. Interviews with administrator and staff also do not corroborate with the allegation. According to the administrator, R1 has not had a cell phone since COVID as R1's family took it for repairs and never returned it. In regards to R1s DMV book, administrator stated it was in R1's backpack the whole time, which was confirmed by R1 that it was there. In regards to R1's miscellaneous paperwork, R1 did not identify what was taken away. According to the administrator and staff, R1 keeps most of their paperwork in their backpack, or bookshelf. LPA checked and observed R1's paperwork in tact in their backpack and bookshelf. Based on the information obtained, there was insufficient evidence that staff confiscated R1's belongings. Therefore the allegation is deemed Unsubstantiated at this time.

Staff violated resident’s personal rights/Staff failed to meet resident’s grooming needs:
In regards to the allegation, it was reported that staff violated R1's personal rights by not letting R1 choose their own hairstyle or wig they want to wear for the day. Interviews with the administrator and staff deny the allegation. Both the administrator and staff state that R1 always has the right to choose their hairstyle and wig they would like to use for the day. Interview with R1 also deny the allegation. R1 stated they've always had the right to choose which wig or hairstyle they can use for the day. Based on the information obtained, there was insufficient evidence to prove that staff violated R1's personal rights by not letting R1 choose their own hairstyle or wig they want to wear for the day. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC9099 (FAS) - (06/04)

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