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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609727
Report Date: 11/04/2024
Date Signed: 11/04/2024 12:28:02 PM

Document Has Been Signed on 11/04/2024 12:28 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: 3DATE:
11/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Tyrone QualsTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On 11/04/2024 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint 31-AS-20241029153645. This Case Management is not related to the original complaint visit. During the facility visit LPA observed that there was a staff member not associated to the facility that has been providing care and supervision to clients.

During LPA’s record review, LPA observed there was a staff member #1 (S1) that was not associated to the facility. Administrator explained that S1 had left in July 2024 but had returned in October 2024 and they must have overlooked re-associating S1. Record review revealed S1 does have fingerprint and background clearance but is not associated to this facility. LPA Casillas explained to the Administrator the importance of associating all staff providing care and supervision to clients and that this citation will result in a civil penalty.

Civil penalty Issued. Appeal rights discussed and provided. Exit Interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 11/04/2024 12:28 PM - It Cannot Be Edited


Created By: Lorena Casillas On 11/04/2024 at 11:22 AM
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: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2024
Section Cited
CCR
80019(f)(1)

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(f) A licensee…may request a transfer of a criminal record clearance from one state licensed facility to another... state licensed facility by providing the following…(1)A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).This requirement is not met as evidenced by:
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Licensee shall submit evidence of transfer request or completion of S1 to this facility. A copy of the receipt shall be provided to CCL/LPA by POC due date.
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Based on interviews and document review, the Licensee did not ensure that S1 was associated to the facility. This poses an immediate health and safety or personal rights risk to 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: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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