197609804-6-1-2023-31-AS-MVAO-CYVQP9-20231226112020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609804
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:47:40 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/24/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230524165815

FACILITY NAME:	ALLIANCE ADULT RESIDENTIAL HOMES INC		FACILITY NUMBER:	197609804
ADMINISTRATOR:	WAKABI, MOSES D		FACILITY TYPE:	735
ADDRESS:	7821 HESPERIA AVENUE		TELEPHONE:	(747) 254-4154
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	4	CENSUS: 4	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Antonia Achieng, House Manager		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility is not following residents IPP plan.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegation. LPAs met with the House Manager and a phone call to the Administrator was made. LPAs explained the reasoon for the visit. LPAs were infomred that the Administrator will not be able to come and designated the House Manager to sign the report.

LPAs conducted physical plant tour at 1:20pm and requested Individual Program Planning (IPP) for four (4) out of four (4) clients and reviewed between 1:30pm – 2:00pm.

On May 8th, 2023, a credible witness conducted an unannounced visit to Alliance Adult Residential Homes, Inc. and only three (3) staff (from 3:25pm to 4:15pm) were present to provide care to four (4) clients. As a level of 4G home with four (4) clients, the facility is required to provide 2:1 staff to C1, 1:1 staff to C2 and 1:1 staff to C3 based on the facility’s approved program design. Based on Regional Center and Alliance Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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 3

Control Number 31-AS-20230524165815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLIANCE ADULT RESIDENTIAL HOMES INC	FACILITY NUMBER: 197609804
	VISIT DATE: 06/01/2023

NARRATIVE

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Adult Residential Homes agreement/ IPP plan, the facility should have at least six (6) staff present to care for four (4) clients.

During today’s visit, LPAs conducted an interview with the Administrator and S1 who confirmed that on 05/08/23 the facility had only three (3) staff members supervising four (4) clients. Based on interviews and record review, the allegation is deemed Substantiated.

Deficiency cited on LIC 9099 D.
Appeal Rights explained. Exit Interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230524165815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLIANCE ADULT RESIDENTIAL HOMES INC	FACILITY NUMBER: 197609804
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/08/2023 Section Cited CCR 80065(a)	1 2 3 4 5 6 7	80065(a) Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee and Administrator shall send the following to LPA: 1. A memorandum of understanding in regard to regulation 80065(a) 2. Facility shall make sure that all staffing ratios are met at all times and will provide LPA with a plan by POC date
	8 9 10 11 12 13 14	Based on interview and record review the licensee did not comply with the section cited above to follow the approve program design with the Regional center regarding the staffing ratio, which poses/posed a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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