197610235-9-7-2022-31-AS-TSMH-CJ2QJQ-20220907121306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 08/24/2022
Date Signed: 09/07/2022 12:13:12 PM

Document Has Been Signed on 09/07/2022 12:13 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WYSE HOME		FACILITY NUMBER:	197610235
ADMINISTRATOR:	LABEODAN, TAYO		FACILITY TYPE:	737
ADDRESS:	35158 WYSE ROAD		TELEPHONE:	(626) 500-1430
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91390
CAPACITY: 4		CENSUS: 1	DATE:	08/24/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Jones Odogwu		TIME COMPLETED:	05:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha Lynn Smith and (LPM) Licensing Program Manager Naira Margaryan conducted a joint subsequent Case Management-Incident visit to this facility with the representatives from North Los Angeles County Regional Center (NLACRC) Venus Rodriguez-Khorasani and Christina Perez.

LPA and LPM met the facility staff and explained that this visit was conducted to follow up and complete investigation of the incident reported to the Community Care Licensing Office (CCLD) on 07/19/2022

It was reported that on 7/14/2022 a staff member #1 (S1) heard a client #1 (C1) talking to someone on the phone and heard the caller was a female. C1 stated to staff member they were talking to the staff #2 (S2). After the phone conversation ended, C1 became upset and start exhibiting behaviors. C1 behavior was triggered by the phone conversation. In addition, C1 told S1 that S2 allowed C1 to touch S2. S2 was removed from work for “Sexual Abuse”.

On 08/19/2022 from 11:15am to 1:00pm, LPA requested and reviewed facility records relevant to investigation. Between 12:50pm and 3:15pm, LPA Smith spoke with the Administrator and three (03) out (04) four facility staff present at the facility. On 08/24/22, LPA Smith and LPM Margaryan spoke with four (04) out of five (05) facility staff who had knowledge of the incident that occurred on 07/14/22.

Interview of the staff did not reveal any credible information to conclude that C1 exhibited a behavior after phone conversation with the female individual (S2). Two (2) out of four (4) staff member stated that S2 was wearing inappropriate attire, triggering C1 to touch S2. However, staff also indicated that S2 was wearing medical scrubs and was unable explain why they considered scrubs inappropriate attire.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/24/2022

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(Cont from 809)
A review of facility records conducted on 08/19/22 and 08/24/22 did not reveal any relevant information to support the issues addressed on the Incident report.

Based on the interviews, observation and record review, it was concluded that C1 had a history of exhibiting aggressive and inappropriate behaviors that may be triggered for various reasons and facility staff should be educated on how to control C1's behaviors.

At the time of this visit LPA Smith and LPM Margaryan noted several Title 22 deficiencies. Therefore, Case management -Deficiency visit was conducted to address noted issues. Additonally, C1’s behavior was posing an imminent threat to CCLD and NLARC personnel. To avoid further complications, the representatives left the facility.

Exit interview conducted. This report was completed outside of the facility and the copy will be e-mailed to the Administrator for manual Signature.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

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