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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609859
Report Date: 03/07/2024
Date Signed: 03/11/2024 02:08:44 PM

Unsubstantiated


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
03/04/2024 and conducted by Evaluator Lorena Casillas
COMPLAINT CONTROL NUMBER: 31-AS-20240304110440
FACILITY NAME:WILLOUBEE RESIDENTIAL IIIFACILITY NUMBER:
197609859
ADMINISTRATOR:HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:3631 E GARNET LANETELEPHONE:
(661) 350-3495
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 4DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jessica HernandezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff pushed resident
Staff did not provide medical treatment to resident
INVESTIGATION FINDINGS:
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This is an amendment to the original report issued 03/07/2024 to add the allegations in the allegations box above.

Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility to conduct an unannounced complaint visit on the above allegations. LPA was granted access by Staff Member #2 (S2), LPA asked S2 to please call Administrator. At 10:15 AM LPA met with Administrator Jessica Hernandez and explained the reason for the visit.

LPA conducted physical plant tour, collected relevant documents, and interviewed staff and clients. A record review was conducted which included, but not limited to Client #1 (C1) IPP and Behavior Plan. LPA requested copies of information pertaining to the investigation including but not limited to all client IPP’s, behavior logs, resident roster, LIC500, Staff Records, Insurance Certificate, and any other documents relevant to the investigation. Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 2
Control Number 31-AS-20240304110440
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: WILLOUBEE RESIDENTIAL III
FACILITY NUMBER: 197609859
VISIT DATE: 03/07/2024
NARRATIVE
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During the course of the investigation Crisis Team, Creating Behavioral Educational Momentum (CBEM) staff arrived for a 10:30 am appointment with Client #1 (C1). C1 refused to be interviewed at the time that LPA asked for an interview. C1 also refused CBEM staff access to enter C1’s room. A few moments later C1 came out into the living room and agreed to be interviewed.

Allegation: Staff pushed resident.

It was alleged that Staff Member #1 (S1) pushed C1 into the wall causing a mark on C1’s back. Interviews with staff and clients revealed that staff have not pushed clients. Two (2) out of four (4) clients did not witness the incident. Staff interviews indicated S1 did not touch or push C1 into the wall. Interview with staff and clients revealed that C1 is aggressive towards S1 constantly verbally attacking S1. Furthermore, interviews with staff and clients revealed that S1 is caring and always tries their best to de-escalate any verbal conflicts with all clients. Based on interviews and observations the allegation, “Staff pushed resident,” is deemed UNSUBSTANTIATED at this time.



Allegation: Staff did not provide medical treatment to resident.

Regarding the allegation, it was alleged that Staff #1 (S1) pushed Client #1 (C1) into the wall, this caused C1 to have back pain that went unattended by medical staff. Interviews with the administrator and staff revealed that C1 has not complained about any back pain for staff to take C1 to seek medical attention. Furthermore, based on interviews with clients and staff it was revealed that S1 did not push C1 into the wall causing any injury, therefore this allegation is deemed UNSUBSTANTIATED.

Exit interview conducted. Copy of this report given to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
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