197609859-4-11-2024-31-AS-NMAN-D8Z4WS-20240910192826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609859
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:39:10 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
09/06/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230906110330

FACILITY NAME:	WILLOUBEE RESIDENTIAL III		FACILITY NUMBER:	197609859
ADMINISTRATOR:	HERNANDEZ, JESSICA I		FACILITY TYPE:	735
ADDRESS:	3631 E GARNET LANE		TELEPHONE:	(661) 350-3495
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 4	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Chanel Williams		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Staff are withholding resident's P&I monies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at approximately 10:45 am. LPA Smith observed surrounding area before contacting the administrator. LPA spoke with the administrator and disclosed the reason for visit. The administrator revealed is at a nearby by facility and is available. Administrator also informed LPA the new staff is authorized to sign report but will send another staff over to sign it. LPA met briefly with staff Tawanna and disclosed purpose of visit is to deliver findings. Chanel arrived later.

Staff are withholding resident's P&I monies.

On 02/28/2024, LPA Smith reviewed facility files and requested copies, interviewed staff and residents, and conducted a physical plant inspection from 11:20 am -4:15 pm. LPA unable to interview Resident #1(R1) as no longer resides at the facility. During initial visit, on 09/06/23, LPA Antonia Alvizar-Ettima conducted tour of
(Cont to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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-20230906110330

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: WILLOUBEE RESIDENTIAL III	FACILITY NUMBER: 197609859
	VISIT DATE: 04/11/2024

NARRATIVE

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(Cont from 9099)

physical plant and requested documents relevant to the investigation.

Interviews with three (3) of three (3) staff revealed staff does not withhold residents’ funds and has not held funds from R1. Administrator also revealed each staff, and the resident or representative must sign log for cash accounting. LPA reviewed Record of cash safeguard for resident receiving cash resources. The log contained entries and signatures in required fields. Interview with three (3) residents revealed have not had any funds withheld to include P&I money. Two (2) of three (3) residents reveal that their funds are handle by parent.

Based on interviews, review of Record of cash log, there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Staff makes residents clean facility walls

Interview with three (3) residents revealed that staff have not made them clean the facility walls. One (1) of three (3) residents revealed will help staff clean facility because they want to help. Interview with three (3) of three (3) staff reveal have not made residents clean facility walls. One (1) of three (3) staff reveal residents in the home are very vocal and regularly voice any issues and will refuse to do anything they do not want to do.

Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Brief tour conducted. No Deficiencies noted at time of visit.

Exit interview conducted/copy of report given

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

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