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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609804
Report Date: 06/11/2024
Date Signed: 06/11/2024 04:34:40 PM

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
06/05/2024 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20240605124830
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: 3DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Moses Wakabi, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff spoke inappropriately towards a client while in care
INVESTIGATION FINDINGS:
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At 09:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit. LPA met with staff, Hariet Huweit, and Administrator was contacted via telephone. LPA explained the reason for the visit. Administrator arrived shortly after.

During course of the investigation, interviews and record review were made. At 09:50 AM, LPA requested resident and staff roster. At 10:00 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:10 AM, LPA conducted a physical pl ant tour. Between 10:20 AM – 01:00 PM, LPA conducted an interview with the Administrator, four (4) Staff, a Witness, and three (3) out of four (4) clients who were available.

Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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-20240605124830
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: ALLIANCE ADULT RESIDENTIAL HOMES INC
FACILITY NUMBER: 197609804
VISIT DATE: 06/11/2024
NARRATIVE
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Staff spoke inappropriately towards a client while in care:

In regard to the allegation, it was reported that staff was speaking inappropriately using an elevated voice to address Client 1 (C1).


On 06/03/2024 an incident occurred at the facility regarding a behavioral issue with C1 getting a full bunch of bananas and not leaving any for other fellow clients. Interview with staff #1 (S1), revealed that staff asked C1 to take one or two bananas and leave some for their fellow housemates. However, C1 reacted which escalated to kicking the trash bin and breaking the bathroom door. Furthermore, administrator and staff informed LPA that the occurrence of the incident with C1 staff did use elevated voice outside of the facility to get C1’s attention in order to facilitate a telephonic communication between C1 and the Administrator. However, interview with C1 revealed that the staff did not make any attempt of facilitating a telephonic conversation between the Administrator and C1 on the day of the incident. Additionally, interview with the witness confirmed that they observed the staff came outside of the facility and seemed visibly upset due to the incident which occurred inside of the facility and did not observe any cellular phone in their hand.
Based on the interviews and (SIR) review during the visit, this allegation is Substantiated at this time.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240605124830
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: ALLIANCE ADULT RESIDENTIAL HOMES INC
FACILITY NUMBER: 197609804
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights (a)...each client shall have personal rights which include,...(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by
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Administrator agreed to hire a licensed vendor to provide training to all staff on Title 22 regarding personal rights regualtions. Proof of training must be submitted by the POC date to LPA.
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Based on Special Incident Report and interviews, the staff spoke to C1 inappropriately while in care to which poses an Immediate Health, Safety or Personal Rights risks to persons 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: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4