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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610200
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:21:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
10/28/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221028145528
FACILITY NAME:PROVIDENCE RESIDENTIAL HOMEFACILITY NUMBER:
197610200
ADMINISTRATOR:WAKABI, MOSESFACILITY TYPE:
735
ADDRESS:16742 OSBORNE STREETTELEPHONE:
(747) 236-4373
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Moses WakabiTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility illegally evicted resident.
INVESTIGATION FINDINGS:
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On 12/02/2022 at 2:35 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced visit on this day in response to the above allegation.

It is alleged the facility illegally evicted resident. During this investigation, LPA interviewed the Administrator on 11/07/2022 and reviewed relevant client records and facility communication records on 11/08/2022. LPA interviewed the complainant telephonically on 11/10/2022. Based on the records reviewed and interviews conducted. On 11/07/22 the administrator confirmed they did not provide an eviction notice to client #1 (C1) or Licensing. On 11/07/2022 the administrator confirmed during an interview, C1 was hospitalized for a psychiatric evaluation after unexpectedly physically assaulting another client after being medically cleared by the hospital, the facility did not pick up C1 due to safety concerns for the other client. Based on the information obtained this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Exit Interview conducted. Copy of this report provided. Appeal Rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
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-20221028145528
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PROVIDENCE RESIDENTIAL HOME
FACILITY NUMBER: 197610200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited
CCR
85068.5(a)(4)
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(a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice...for any of the following reasons: (4)...the client's needs cannot be met by the facility...The licensee did not comply with the above cited section, as evidenced by:
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The Administrator will review Section 85068.5(a)(4) and will submit to LPA a written explanation on how they will assure to follow Title 22 Regulations with regards to following requirements.
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Based on interviews conducted facility failed to provide C1 with a proper eviction notice and failed to pick up C1 when they were discharged from the hospital which posed a potential health and safety risk and violation of Personal Rights to residents 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2