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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610200
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:26:54 PM

Document Has Been Signed on 12/02/2022 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Moses WakabiTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced case management visit to this facility to cite deficiencies discovered during the course of investigating a complaint 31-AS-20221028145528.

LPA met with administrator Moses Wakabi and explained the reason for the visit. During the complaint investigation, while reviewing facility documents on 11/07/2022 and 11/08/2022, LPA found out that the facility had no signed admission agreement with Client #1 (C1) on file. LPA interview with the administrator on 11/07/2022 confirmed that C1 had no signed admission agreement on file. LPA confirmed with North Los Angeles County Regional Center (NLACRC) an admission agreement was not signed on behalf of C1.



Deficiencies issued (refer to 809D). Appeal right provided. Exit interview conducted. Copy of this report issued.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2022 03:26 PM - It Cannot Be Edited


Created By: Evelin Rios On 12/02/2022 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
12/02/2022
Section Cited
CCR
80068(a)(1)

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80068(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative...(1)Prior to admitting a ...adult recomended by a Regional.The licensee did not comply with the above cited section, as evidenced by:
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The licensee is in contact with Regional Center and will assure to obtain a copy of admission agreement before admitting another client to facility. C1 no longer in the facility. No POC required.
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Based on client #1’s (C1) record review, (C1) was missing an admission agreement, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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