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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610235
Report Date: 09/12/2022
Date Signed: 09/12/2022 11:45:09 AM

Substantiated


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
07/08/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220708094932
FACILITY NAME:WYSE HOMEFACILITY NUMBER:
197610235
ADMINISTRATOR:LABEODAN, TAYOFACILITY TYPE:
737
ADDRESS:35158 WYSE ROADTELEPHONE:
(626) 500-1430
CITY:SANTA CLARITASTATE: CAZIP CODE:
91390
CAPACITY:4CENSUS: 1DATE:
09/12/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yadira Delgado TIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff are not following a client's needs and services plan
Staff did not meet the minimum qualifications
Staff did not properly report an incident involving a client
Facility does not have adequate staffing to provide care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith and Wendell Smith conducted a complaint visit to this facility on 09/12/22 at 10:00 am to deliver findings.
Licensing Program Analyst (LPA) Tihesha “Lynn” Smith made a subsequent complaint visit to this facility on 08/19/22. LPA met with David Avila and Los Angeles Regional staff at 11:20 am and explained the reason for this visit.
During initial visit, on 07/15/22, LPA Smith reviewed facility files between 11:40 am to 12:20 pm and obtained copies of pertinent documents. LPA conducted interviews with staff between 12:30-3:00 pm. LPA conducted a physical plant tour between 3:30pm- 4:15 PM.
Staff are not following a client's needs and services plan
It was alleged that the staff are not following client’s needs and services plan. LPA record review revealed that per Resident #1 (R1) individual Program Plan (IPP), R1 requires 3:1 care and supervision with the three (3) assigned staff to maintain line of sight and arm’s length distance of R1. On 07/15/22 and on 08/19/22, LPA Smith observed R1 entering garage office several times without assigned staff including assigned staff being indoors while R1 was outdoors.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
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 4
Control Number 31-AS-20220708094932
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: WYSE HOME
FACILITY NUMBER: 197610235
VISIT DATE: 09/12/2022
NARRATIVE
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(Cont from (9099)

LPA Smith interview with staff revealed that 3:1 not always maintained during some shifts. Information revealed from the interviews confirmed the facility is understaffed and the facility affected by high turnover of personnel.
Based on the information gathered during previous licensing visits, observation, and interviews there is a sufficient pertinent information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.Staff did not meet the minimum qualifications
It was alleged that staff did not meet the minimum qualifications. Overall interviews with the staff confirmed that some staff are not completely finished with trainings required by position. A review of personnel files revealed training information and specific training topics and hours for 11 out of 22 staff records were missing or incomplete. First Aid/CPR, CPI training and training certificates were expired or not available for at least seven (7) staff members.

Based on the information gathered during this and previous licensing visits and interviews there is sufficient pertinent information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. No citation was issued at this time. The facility was cited for this issue during Case Management Deficiency visit conducted on 08/24/2022

Staff did not properly report an incident involving a client

It was alleged that staff did not properly report an incident involving a client #1 (C1). LPA Smith interview with administrator revealed that administrator did not report or was not aware of what incidents should be reported to the Licensing office. During review of facility documents obtained on 07/15/22 and on 08/19/22 and from a review of R1 medications LPA discovered several incidents posing hazards to C1’s health and safety were not reported to the Licensing Department.

Based on the information gathered during this and previous licensing visits, interviews there is sufficient pertinent information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Please issue citation under the reporting requirements.

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

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220708094932
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: WYSE HOME
FACILITY NUMBER: 197610235
VISIT DATE: 09/12/2022
NARRATIVE
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(Cont from 9099C)

Facility does not have adequate staffing to provide care and supervision

It was alleged that the facility does not have adequate staffing to provide care and supervision. LPA Smith interview with administrator confirmed that facility requires five (5) staff to be present in the facility. The administrator also confirmed the facility does not have adequate staffing and routinely there are only four (4) staff per shift. During prior licensing visits LPA observed three (3) to (4) staff present in the facility. On 07/15/22 there were only 2 staff supervising C1 and C1 was able to get into LPA Smith’s personal space and grabbed files from the desk.

Based on the information gathered during this and previous licensing visits, interviews, and observation there is sufficient pertinent information to support the allegation. Therefore, the allegation is currently SUBSTANTIATED at this time. No citation was issued at this time. The facility was cited for this issue during Case Management Deficiency visit conducted on 08/24/2022

Exit interview conducted/Copy of Report and Appeal Rights emailed

Under Title 22 Regulations, following citations were issued and recorded on LIC9099D

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

DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220708094932
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: WYSE HOME
FACILITY NUMBER: 197610235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2022
Section Cited
CCR
85065.5
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85065.5 Day Staff-Client Ratio
(a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met:
(1) For Regional Center clients, staffing
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Administrator to send POC and updates regarding staffing progress. POC due date: 09/21/22
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shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients. This requirement was not met as facility only had three to four staff working during previous visits.
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Type B
09/21/2022
Section Cited
CCR
80061(b)(2)
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Reporting Requirements- Written report shall be submitted to the licensing agency within seven days following the occurrence of such event.
This requirement was not met as evidenced by:
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Administrator will send written statement that all incidents will be reported in the required timeframe.
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Based on documentation obtained facility failed to submit written incident report within the seven day window and was submitted two days past the due date which posed a potential health and safety risk to clients 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: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4