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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609942
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:07:12 PM

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
12/06/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20221206092454
FACILITY NAME:WILLOUBEE'S PARADISE LIGHTHOUSEFACILITY NUMBER:
197609942
ADMINISTRATOR:HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:6025 LIGHTHOUSE LANETELEPHONE:
(661) 350-3495
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:4CENSUS: 3DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jessica Hernandez, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with the Administrator and explained the reason for the visit.

Allegation: Staff mismanaged resident's medication. To investigate this allegation, from 2:00pm to 2:40pm, LPA conducted interviews and reviewed documents pertaining to the allegation. It was reported that on 11/19/22, C1 moved into a new facility around 1:00pm without receiving their six (6) morning medications as prescribed. Moreover, along with C1’s medications, the new facility received another consumer’s (C2’s) three (3) medications in error. During today’s visit, LPA confirmed and identified that the facility did not properly administer medications to clients. In addition, the Administrator Jessica Hernandez also admitted the medication error. This is an immediate health and safety risk to clients in care. Therefore, based on interviews and documents reviewed, the allegation “Staff mismanaged resident's medication” is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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-20221206092454
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'S PARADISE LIGHTHOUSE
FACILITY NUMBER: 197609942
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2022
Section Cited
CCR
80075(5)(B)
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Health Related Services: (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication.... facility medication is given according to the physician orders.

This requirement was not met, evidenced by:
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Administrator has agreed to submit CCL vendor trainig and staff signatures pertaining to administering medication to clients in care. Administrator will email LPA informing when the training will be conducted.
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Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by not administering medication according to doctor's orders, which poses an immediate health and safety risk 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: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2