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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610200
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:15:16 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
05/01/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230501093302
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:
05/19/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Krisha WakabiTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility staff took punitive actions against a resident
Facility staff spoke inappropriately to a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility 9:35 am. LPA Smith met with staff and disclosed the purpose of this visit. The administrator was contacted and authorized facility staff to sign.

Facility staff took punitive actions against a resident
It was alleged that that facility staff took punitive actions against Resident #1 (R1). During initial visit on 05/09/2023, LPA Smith conducted tour of physical plant at approximately 9:45 am, conducted interviews with staff and client, reviewed facility records, and requested documents relevant to the investigation from approximately 10:03 AM – 12:55 pm. During subsequent visit at 9:35 am on 05/19/23, LPA conducted interviews with staff and client from approximately 10:00 am- 1:00 pm. R1 and Resident #2 (R2) were not present at the facility during LPA visits. Interview with two (2) of four (4) residents revealed they have not had staff take punitive action against them and have not witnessed any other resident have punitive
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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-20230501093302
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: PROVIDENCE RESIDENTIAL HOME
FACILITY NUMBER: 197610200
VISIT DATE: 05/19/2023
NARRATIVE
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(Cont from 9099)

action taken against them by facility staff. Three (3) out of (7) staff not available for interview. Interview with four (4) out of seven (7) staff revealed that have not taken punitive action against residents and have not witnessed any facility staff taking punitive action against residents. Interview with three (3) of seven (7) staff revealed law enforcement contacted for R1 on 04/29/23 due to R1 threatening and chasing staff with a knife, yelling obscenities, and unable to de-escalate R1 aggressive behaviors.

Based on interviews during this and previous licensing visits there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Facility staff spoke inappropriately to a resident

It was alleged that facility staff spoke inappropriately to a resident. Interview with two (2) of four (4) residents conducted on 05/09/23 and 05/19/23 revealed facility staff did not speak inappropriately to them, and they have not witnessed staff speaking inappropriately to residents. Two (2) out of four (4) residents revealed staff may speak firmly but not inappropriately. Two (2) out of two (2) residents also revealed they have witnessed a resident speak inappropriately or yell at staff or themselves have spoken to staff inappropriately but apologized for their behavior because the staff in the facility are kind. Four (4) out of seven (7) staff revealed they have not spoken inappropriately to any residents and have not witnessed any staff speaking inappropriately to residents.

Based on interviews during this and previous licensing visits there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
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