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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609804
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:19:56 PM

Document Has Been Signed on 04/30/2024 03:19 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:ALLIANCE ADULT RESIDENTIAL HOMES INCFACILITY NUMBER:
197609804
ADMINISTRATOR/
DIRECTOR:		WAKABI, MOSES DFACILITY TYPE:
735
ADDRESS:7821 HESPERIA AVENUETELEPHONE:
(747) 254-4154
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
04/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:16 PM
MET WITH:Moses Wakabi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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At 12:15 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an announced case management visit. LPA met with Administrator and disclosed the reason for the visit.

It was reported by a credible witness that on 03/27/2024, she conducted an annual visit to the above facility and the following deficiencies were noted:

Staff # 1 (S1) hire date 03/01/2021,did not have a required DSP II training on file. LPA conducted a file review of S1 and observed S1 completed the required training on 04/24/2024.

Staff # 2 (S2) hire date 07/01/2023, did have finger print clearance; however, was not associated to work at the above facility. LPA conducted a record review and Licensing Information System (LIS), and observed that S2 is associated since 03/29/2024.

Staff # 3, fingerprint clearance is pending with the department. Administrator informed LPA that S3 is not working at the facility currently. Upon receiving the fingerprint clearance, S3 will be appointed as a staff; and therefore, Administrator allows S3 to take all required training via zoom with all other staff. S3 never comes to the facility to provide care and supervision to clients.

During the credible witness visit on 03/27/2024, it was reported that Staff # 4, and Staff # 5, were not registered on LIC 500 and the facility could not provide files upon request. Based on record S4 was disassociated on 11/10/2023 and S5 was disassociated on 11/15/2023. Therefore, S4 and S5 were not registered on LIC 500 and files were unavailable to the credible witness.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/30/2024 03:19 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/30/2024 at 02:38 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: ALLIANCE ADULT RESIDENTIAL HOMES INC
FACILITY NUMBER: 197609804

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2024
Section Cited
CCR
80065(i)(2)

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80065 Personnel Requirements; (i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f. This requirement is not met as evidenced by;
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Staff # 2 associated with facility as of 03/29/2024, POC cleared during the visit.
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Based on the interviews and record review S2 was present at the facility without criminal record association to the facility. this poses immediate risk to the health and safety of the clients in care.
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Type B
04/30/2024
Section Cited
CCR85165(h)(1)(A)(B)

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(h)The licensee shall maintain a written record of the staff training. (1) Documentation of the training received by each staff..., pursuant to Section 80066, and include: (A) Dates, hours, and description of...training.
(B) This requirement is not met as evidenced by;
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Staff # 1, completed the required traning on 04/24/2024. POC cleared during the visit.
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Based on interview and record review, S1 did not have DSP II required training upon the second year of employemnt, which poses a potienal risk to the health and safety of 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:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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