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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609804
Report Date: 06/08/2023
Date Signed: 06/08/2023 11:56:03 AM

Substantiated


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 INCFACILITY NUMBER:
197609804
ADMINISTRATOR:WAKABI, MOSES DFACILITY TYPE:
735
ADDRESS:7821 HESPERIA AVENUETELEPHONE:
(747) 254-4154
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:4CENSUS: 4DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Moses TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident has access to medications resulting in resident overdosing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shira Stamps arrived at the facility at approximately 10:40 am for a subsequent complaint visit. Staff member David called the Administrator. LPA spoke to the Administrator over the phone, and informed him of the purpose of this visit. The Administrator disagreed with LPAs findings and refused to sign the report. The Administrator requested to speak to a supervisor. LPA provided the Administrator with the supervisor’s name and advised him to call the local office.

Entrance interview conducted over the phone.

On 04-04-2023 LPA conducted a complaint investigation. Based on the information at the time the finding were unsubstantiated.

On 05-23-2023, the department received additional information which will change the findings of this complaint. CONTINUED...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
80075(k)(1)
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Health Related Services(k)(1)Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement was not met as evidience by:
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The Administrator will conduct in service training with all staff members regarding the section cited above and how to properly conduct a search for C1. The Administrator will provide LPA with training materials and signatures of all staff that have completed the training.
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Based on interviews, the Licensee did not comply with the section cited above in that the Licensee did not properly search C1 after an elopment and remove/lock away medications in C1's posession which poses an immediate health and saftety risk to clients in care.
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Type B
06/15/2023
Section Cited
CCR
80061(b)
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80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.
This requirement was not met as evidence by:
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The Administrator will conduct in service training reviewing the regulation section about reporting requirements. The Administrator will provide all training materials and signatures of all staff that have attended the training by the POC due date.
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Based on file document review, the Licensee did not comply with the section cited above in that the Licensee did not notify the department of a special event that occurred on 3/24/23 when C1 was taken to the hospital for an overdose which poses a potential health and safety 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 06/08/2023
NARRATIVE
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Allegation: Resident has access to medications resulting in resident overdosing.

On 4/4/23 Licensing Program Analyst (LPA) Shira Stamps conducted an initial complaint visit and interviewed staff and clients. LPA interviewed four (4) staff members. On 4/4/23 at 11:45am, LPA reviewed one (1) out of four (4) client files which include but not limited to the residents IPP(12/15/20), behavior plan(February 2023), written authorization to search 1/02/23 physicians report 7/08/22), On 5/24/23 LPA reviewed the discharge document 3/24/23).

The complainant concern is allegedly Client one (C1) eloped from the facility without a staff member supervision and went into a store and had access to Benadryl. C1 brought the Benadryl into the home, staff did not properly assess C1 before attending the day program as a result C1 overdosed and was hospitalized.

On 3/24/23 while attending Day program, C1 approached staff and told staff that 6 Benadryl were taken the evening before because C1 was unable to sleep. Out of concern C1 was taken to the hospital ER. While in the hospital a significant amount of Benadryl pills was found inside C1’s underwear in a sock. C1 was assessed and based on medical discharge diagnosis 3/24/23, indicates intentional overdose, however it was not terminal.

C1 is intellectually disabled and according to the physician’s report C1 is unable to leave the facility unassisted and requires care and supervision when leaving the home. Review of Behavior plans and IPP indicates that C1 has a history of eloping/stealing and needs care and supervision when leaving the home. While C1 needs supervision when leaving the facility C1 is able to verbally communicate with staff.

Staff interviews indicate that C1 is searched every day and was searched on the day of the incident. Staff indicated they did not keep a log of each search but indicated they did not find medications on C1 that day.

Facility staff indicated C1 goes out in the community at day program, and C1 could have gotten the medications while in day program. Day program staff indicated C1 was also searched that day.

According to client interviews, C1 left the facility out of the back entrance during the evening and walked to a store and stole the Benaldryl and returned home and concealed the medication. Staff never knew C1 left the home.

CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 06/08/2023
NARRATIVE
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Facility staff did not consider C1’s behavior history and did not provide proper supervision at all times to prevent the client from leaving the home thus gaining access to medications which led to the intentional overdose.

Therefore, the findings have changed from unsubstantiated to SUBSTANTIATED.

Deficiencies and appeal rights issued. Copy of report left for Administrator.

Exit interview conducted over the phone. Administrator refused to sign the report.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4