197609804-4-4-2023-31-AS-NGID-CT6SF2-20230626134933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609804
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:43:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/28/2023 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20230328101814

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:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Antonia Achieng , Co-Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident has access to medications resulting in resident overdosing.

INVESTIGATION FINDINGS:

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At 10:20am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above to conduct an initial complaint visit. LPA met with Co-Administrator Antonia Achieng since the Administrator was sick and could not come to the facility. LPA explained the purpose of this visit to the Administrator over the phone.At approximately 10:45 am, LPA conducted a physical plant walk through. From 11:00am-12:00pm, LPA conducted interviews with staff, clients, and collected relevant documents.

Allegation: Resident has access to medications resulting in resident overdosing.

It is alleged that Client one (C1) eloped from the facility without a staff member and went into a store and had access to Benadryl. It is alleged that C1 brought the Benadryl into the home and staff did not properly search C1 before attending the day program. LPA interviewed four (4) staff members. Staff interviews indicated that C1 is searched everyday including underwear and socks before going onto the van for day program. It was indicated C1 was searched that morning before the incident and no medication was found on the client.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230328101814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLIANCE ADULT RESIDENTIAL HOMES INC	FACILITY NUMBER: 197609804
	VISIT DATE: 04/04/2023

NARRATIVE

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Staff interviews indicated they believe C1 got the medication while in the care of the day program staff. LPA interviewed three (3) out of four (4) clients. It was indicated by clients that they have never seen medication accessible to them. Document review shows C1 signed a consent form for facility staff to search C1 including socks and the underwear area. It was indicated through interviews that C1 eloped without a staff member the night before and got access to Benadryl at a store, but document review indicated C1 last eloped on March ,2023. Two (2) individuals out of six (6) indicated C1’s pockets were only searched before leaving the facility. Four (4) out of six (6) interviews indicated C1 was fully searched before entering the day program van including socks and underwear. LPA was unable to obtain a log from facility staff or the day program staff verifying C1 was fully searched that day. Therefore, due to lack of supportive evidence it is unknown if C1 got the Benadryl under the supervision of facility staff or day program staff and the allegation, “Resident has access to medications resulting in resident overdosing,” is deemed unsubstantiated.

Exit interview conducted. Copy of report delivered to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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