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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609727
Report Date: 05/28/2024
Date Signed: 05/28/2024 12:34:00 PM

Document Has Been Signed on 05/28/2024 12:34 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WE R ONE FAMILY HOME, INC.FACILITY NUMBER:
197609727
ADMINISTRATOR/
DIRECTOR:		TYRONE QUALSFACILITY TYPE:
735
ADDRESS:723 E. OLDFIELD STTELEPHONE:
(562) 644-7260
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
05/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Vashan BobneyTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 05/28/2024 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint #31-AS-20240523125725. This Case Management is not related to the original complaint visit. During the complaint investigation LPA observed that facility did not report an incident that occurred on 05/15/24. LPA Casillas met with House Manager, Vashan Bobney. Administrator was called and assigned House Manager to sign this report, as he could not meet LPA.

During records review LPA noticed that there was no incident report submitted to Community Care Licensing (CCL) for an incident that occurred on 05/15/24. LPA interviewed House Manager and it was discovered that an incident report was not made to Community Care Licensing (CCL). House manager was not able to produce confirmation for reporting the incident.

LPA Casillas explained to House Manager the need and importance to report any and all incidents to CCL in a timely manner. LPA explained to House Manager that vendorized training would have to be submitted to LPA by 06/04/24 via email.

Please see LIC9099-D.

Citation Issued. Appeal rights discussed and provided. Exit Interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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 05/28/2024 12:34 PM - It Cannot Be Edited


Created By: Lorena Casillas On 05/28/2024 at 12:22 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: WE R ONE FAMILY HOME, INC.
FACILITY NUMBER: 197609727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2024
Section Cited
CCR
80061(b)

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80061(b)Upon the occurrence... of any of the events specified…next working day during its normal business hours. In addition, a written report containing the information…shall be submitted to the licensing agency within seven days...This was not met in evidence by:
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House Manager agrees to an approved verndor Reporting Requirements training for all staff. House Manager will email proof of correction to LPA by POC due date.
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Based on interviews, observations and documentation review an incident occurred on 05/15/24 and it was not reported in a timely manner, which poses a potential health and safety risk to the clients 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Lorena Casillas
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2024


LIC809 (FAS) - (06/04)
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