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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610235
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:54:11 PM

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
01/27/2023 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20230127102011
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:
02/09/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:La Quencia DavisTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility does not have adequate staffing to provide care and supervision
Staff are not following a client's needs and services plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha Smith conducted a complaint visit to this facility on 02/09/23 at 11:30 am to deliver findings.
During initial visit, on 02/02/23, LPA Smith conducted a physical plant tour at 10:15 am, conducted interviews with staff, requested and reviewed pertinent documents relevant to the investigation from 10:45 am-3:00pm.

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.
During initial visit conducted on 02/02/23 LPA Smith observed three (3) staff present at the facility. A fourth staff arrived later and upon their arrival one of the staffs left for the day.
LPA Smith interview with five (5) out of five (5) staff reveal the home still has staffing issues and only three (3) staff were present in facility most of the time. As per facility program plan and based on the staff to
( Cont to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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 3
Control Number 31-AS-20230127102011
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: 02/09/2023
NARRATIVE
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Cont from 9099)

client ratio approved by the North Los Angeles Regional Center (LARC) there shall be five (5) staff present at the facility at all times.

Based on interviews and observation there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

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.

During initial visit conducted on 02/02/23 LPA Smith observed three (3) staff present at the facility. LPA record review revealed that per Client #1 (C1) individual Program Plan (IPP), C1 is on a 3-1 ratio with two (2) additional staff in the house for a total of five (5) staff present to consistently be maintained every day and on every shift. Staff interviews also revealed that on December 24th, 2022, only one (1) staff was working during night shift in the facility.

Based on observation, interviews, and record review, there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.



At the time of this visit LPA Smith informed the administrator that immediate civil penalty of $500.00 will be assessed to the facility due to failure to provide required care and supervision to facility client.
In addition, the Administrator was advised that a civil penalty of $250.00 will be assessed for receiving a repeat violation of the same Title 22 Regulation within 12-month period.

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

No other immediate health and safety hazard were noted during this visit as LPA was working outside of the facility due to the health and safety concerns based on Client #1 (C1’s) aggressive behavior(s).

Exit interview was conducted, appeal rights and copy of report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230127102011
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: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
80078
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80078- Responsibility for Providing Care & Supervision (a) The licensee shall provide care and supervision as necessary to meet the clients' needs.
This requirement was not met as evidenced by:
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Licensee and Administrator shall send the following to LPA:
1. A memorandum of understanding in regard to CCR 80078
2. Staff schedule for the next week (02/13/23 to 02/17/2023)
by POC date:02/10/2022
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 Licensee failed to ensure to provide necessary care and supervision to meet client's needs. Licensee failed to maintain a minimum of 5 staff per shift at facility at all times. This poses an immediate health and safety risk to clients in care.
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Type A
02/10/2023
Section Cited
CCR
80065(a)
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80065(a) Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
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Licensee and Administrator shall send the following to LPA:
1. A memorandum of understanding in regard to regulation 80065(a)
2. Facility shall make sure that all staffing ratios are met at all times and will
provide
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The Licensee did not ensure that client has 3:1 ratio at all times to provide services to meet individual need of the client.This poses a potential health and safety risk to clients in care.
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LPA with a plan on how to meet this need
by POC date: 02/10/2023

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: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3