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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609942
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:11:27 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.ASC, 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
12/03/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20241203110904
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: 4DATE:
12/09/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Dajia Shannon TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained an unexplained injury
Staff did not inform authorized representatives of incident
INVESTIGATION FINDINGS:
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On 12/09/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the caregiver. LPA explained the purpose of this visit was to review residents’ files, conduct interviews, and present findings.

LPA conducted a physical plant tour at 9:45 am until 10:00 am. LPA reviewed the residents’ files at 10:00 am until 10:20 am. LPA Spaeth requested copies of residents’ documentation, and incident reports. LPA received the documentation during the visit.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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-20241203110904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE'S PARADISE LIGHTHOUSE
FACILITY NUMBER: 197609942
VISIT DATE: 12/09/2024
NARRATIVE
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LPA interviewed one out of four clients at 10:20 am until 10:40 am. LPA interviewed the Administrator at 10:40 am until 10:50 am. The house manager arrived at 11:45 am. LPA Spaeth interviewed three (S1, S2, and S3) out of four staff at 11:00 am until 12:00 pm.

Regarding the allegation: Resident sustained an unexplained injury. It’s being alleged a client had a head injury on 11/24/2024 and the Administrator was unaware an injury occurred. S1-S3 and the Administrator all confirmed C1 did not have a head injury on 11/24/2024. A client (C2) confirmed they did not observe a head injury on C1. Three clients (C2, C3, and C4) were unavailable for an interview.

Regarding the allegation: Staff did not inform authorized representatives of incident. It’s being alleged the client’s head injury was not reported to the responsible parties. S1-S3 and the Administrator stated the responsible parties were not notified because C1 did not have an injury on 11/24/2024.

Based upon client, staff and Administrator interviews, the allegation is unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2