<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609727
Report Date: 01/13/2025
Date Signed: 09/12/2025 10:20:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/24/2024 and conducted by Evaluator Lorena Casillas
COMPLAINT CONTROL NUMBER: 31-AS-20240924102410
FACILITY NAME:WE R ONE FAMILY HOME, INC.FACILITY NUMBER:
197609727
ADMINISTRATOR:TYRONE QUALSFACILITY TYPE:
735
ADDRESS:723 E. OLDFIELD STTELEPHONE:
(562) 644-7260
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 3DATE:
01/13/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tyrone QualsTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff inappropriately restrained resident resulting in resident sustaining a fracture.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended copy of the report previously issued on 01/13/2025. After review of this complaint, it was determined corrections to the verbiage was warranted to correct the Health and Safety Code.

An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Lorena Casillas to issue the findings of the above listed allegation.

On 09/24/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation: Staff inappropriately restrained resident resulting in resident sustaining a fracture.

On 09/25/2024 an initial visit was conducted by LPA Casillas. On that day LPA conducted tour of the facility, interviewed with facility staff, and obtained copies of pertinent information related to the investigation.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20240924102410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 01/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This complaint investigation was conducted by Jose Santana, Investigator from Community Care Licensing Division’s Investigations Branch (IB) along with LPA Casillas. The investigation consisted of interviews by IB with eleven (11) witnesses, five (5) facility staff, facility Administrator, four (4) out of four (4) facility clients, two (2) hospital staff/specialists, reviews of C1’s medical record, police records pertaining to the incident, and facility program plan.

The investigation findings revealed that C1 sustained a humerus fracture to C1’s right arm on Sunday, 9/22/2024, as a result of an inappropriate manual restraint by facility staff #1 (S1). According to staff C1 had a behavior due to C1 wanting additional food than what was provided by staff. C1 rushed to the visible leftover food and when staff intervened C1 began an episode of attacking staff. C1 was involved in a prolonged restraint by two (2) 360 Behavioral Health staff prior to S1’s involvement, but C1 was still able to lift their subsequently injured right arm after S1 arrived, indicating it was most likely not yet fractured until S1 intervened. According to witnesses, S1 held C1’s right arm behind C1’s back as S1 accidentally fell onto C1. During Investigator Santana’s interview with S1, S1 stated that “placing a client’s arm behind their back is one of the CPI techniques that was taught” however S1 admitted that they did not use an appropriate manual restraint. During LPA’s record review of the facilities program plan it was discovered that the facility did not follow their program plan which states “…all physical interventions taught are designed to be non-harmful, non-invasive, and to maintain the individual’s dignity” (pg 107 & 108). Additionally, it appears that facility staff did not follow the facility’s expected crisis response when it failed to call CBEM (the crisis response team) at any time during the hour long behavioral episode that C1 was having. This process was explained by staff during interviews and confirmed by C1’s behaviorist as a plan in place for a crisis. Furthermore, it is indicated in the program plan that physical restraint is to be used as a last resort, however based on interviews with staff and witnesses, no other techniques were applied. “Instead, staff should utilize geographical containment procedures. These procedures utilize the physical environment in such a way that attempts at assault are prevented.” Pg 98. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the allegation that staff inappropriately restrained resident resulting in resident sustaining a fracture is therefore Substantiated.


A $500 immediate civil penalty is assessed today for a violation resulting in injury to C1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1548.
Exit interview conducted. Civil penalties assessed. Appeal rights explained and provided. Report reviewed. The Administrator refused to sign the amended report and a copy of the report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240924102410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2025
Section Cited
CCR
85102(a)(7)
1
2
3
4
5
6
7
(a) The following emergency interventions shall not be used on a client (7) Manual restraint with the person’s hands held or restrained behind the person's back. This was not met as evidence by:
Based on observations, record reviews and interviews, licensee failed to ensure
1
2
3
4
5
6
7
Licensee discussed and agreed to vendorized training on Emergency Intervention Prohibitions for all staff by POC due date. Proof attendance with staff signatures shall be emailed to LPA by POC due date.
8
9
10
11
12
13
14
that staff do not perform prohibited intervention techniques. As a result, staff engaged in prohibited intervention techniques in which C1 suffered a fracture to the right arm. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
01/14/2025
Section Cited
CCR
85165(a)
1
2
3
4
5
6
7
(a) The licensee shall ensure staff who use, participate in, approve. or provide visual checks of manual restraint or seclusion only use techniques specified in the Emergency Intervention Plan and which are not prohibited in Section 85102. This was not met as evidence by:
1
2
3
4
5
6
7
Licensee discussed and agreed to vendorized training on Emergency Intervention Staff Training for all staff by POC due date. Proof attendance with staff signatures shall be emailed to LPA by POC due date.
8
9
10
11
12
13
14
Based on observations, record reviews and interviews, the licensee failed to call CBEM as indicated by C1’s behaviorist as the first instruction to C1’s escalating behaviors, instead an improper physical hold was performed, this poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20240924102410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2025
Section Cited
CCR
80072(a)(1)
1
2
3
4
5
6
7
(a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This was not met as evidence by:
1
2
3
4
5
6
7
Licensee discussed and agreed to additional vendorized training Personal Rights for all staff. Additionally, Licensee will submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR 80072. Proof attendance with staff signatures and
8
9
10
11
12
13
14
Based on observations, record reviews and interviews the Licensee failed to ensure that clients personal rights were protected in which staff fractured C1’s arm during a prohibited emergency intervention. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
written letter shall be emailed to LPA by POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4