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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610200
Report Date: 02/04/2025
Date Signed: 02/04/2025 11:25:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/18/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20241218130415
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:
02/04/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Richard Kamiiza- designeeTIME COMPLETED:
11:43 AM
ALLEGATION(S):
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Due to neglect/lack of care and supervision, client AWOLed from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Moses Wakabi, and advised them about the visit. At 9:40AM LPA conducted a physical plant tour to ensure the health and safety of the clients in care.

An entrance interview was conducted.

Allegation #1: Due to neglect/lack of care and supervision, client AWOLed from facility

Regarding the above allegation, it is alleged that the facility staff neglect/lack of care and supervision, client AWOLed from facility.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 3
Control Number 31-AS-20241218130415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PROVIDENCE RESIDENTIAL HOME
FACILITY NUMBER: 197610200
VISIT DATE: 02/04/2025
NARRATIVE
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On 12.23.2024, LPA requested copies of facility documents relevant to the investigation at 2:50 PM. LPA reviewed facility documents interviewed staff and clients between 2:30 AM to 3 PM. LPA interviewed the Administrator, one (1) out of two (2) staff, and one (1) out of four (4) clients, who are in the facility. Interviews revealed that staff left the client at the dining table to grab some milk for the client at 8AM. It was after a few minutes that staff #2 (S2) realized that client #1 (C1) left the facility through the front door of the facility. Facility tried searching within the surroundings for C1 and also called 911. Paramedic found C1 after around 8:30AM at the bottom of the LA river close to Parthenia and Hayvenhust, which is one (1) mile from the facility.

Based on observations, record reviews, and interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241218130415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PROVIDENCE RESIDENTIAL HOME
FACILITY NUMBER: 197610200
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2025
Section Cited
CCR
85065(b)
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The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
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Licensee will provide an in-service training to ensure that all of the residents are observed 24 hours a day. Licensee will submit in-service to LPA by POC due date.
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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: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3