197610235-9-7-2022-31-AS-TSMH-CJ2Q5S-20220907115227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 08/31/2022
Date Signed: 09/07/2022 11:52:48 AM

Document Has Been Signed on 09/07/2022 11:52 AM - 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:	08/31/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	David Avila		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An Informal Conference was held on this date at the Woodland Hills Adult and Senior Care Regional Office (WHS ASC RO). Present during the meeting were: Licensee representatives Elwyn RM for Southern California- Christine Surla Elwyn QMA- Paul Ramos Elwyn-Wyse Administrator (via phone)- David Avila WHS RO Regional Manager (RM) Angela Kendrick Licensing Program Manager (LPM) Naira Margaryan Licensing Program Analyst (LPA) Tihesha Smith North LA Regional Center (NLARC) Quality Assurance Manager (QAM) Venues Rodriguez-Khodabasi Informal Conference process was explained to the Licensee. The purpose of today's Informal Conference is to discuss the deficiencies that have been cited during recent Licensing Visits conducted Jointly with the North Los Angeles Regional Office (NLRC) representatives. The Licensee was informed that this Informal Conference is part of the administrative action process and if these issues are not resolved, it may result in a formal Non-Compliance Conference and may lead to a referral to the Department's Legal Division for a possible revocation action.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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: 08/31/2022

NARRATIVE

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(Cont from 809)
Issues discussed in the meeting:

Physical plant
Garage is used as office
Both doors were unlocked (1 was broken) – cleaning solutions were accessible. Garage door frame was broken, unable to lock. Several cabinets were broken in the garage.
Kitchen- facility had insufficient quantity and variety of perishable and nonperishable food supply. Cabinet under the sink - lock was broken and cleaning solutions accessible.
Laundry room-Unlocked, cleaning solutions accessible.
Walls/Doorways-Had stains and needed to be wiped down
Insufficient number of qualified personnel
During Licensing Visits conducted on 08/19/22 and 08/24/22 there were insufficient staffing present at the facility. There were not enough Leads and/or staff leaving shifts without Leads. The administrator confirmed that high turnover of the personnel impacted the facility.

Personnel files
At the time of this visit Personnel files were reviewed and the files were incomplete
Staff training requirements
The 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 certificates, training certificates were expired or not available for at least seven (7) staff members.
Medications. During licensing Visits, Client one’s (C1’s) medications was not dispensed per doctors’ instructions.
AM meds for August 15, 16, 19, and 24 were missed. This was identified and discussed with the Administrator along with NLARC staff.
Neglect in care and supervision. During this informal conference the care and supervision of the facility client was discussed. On 08/19/22 and 08/24/22, C1 was observed and assessed and facility staff providing care and supervision to C1 were interviewed. Based on observation and interviews it was concluded that three (03) facility staff assisting the client #1 (C1) were unable to redirect C1 while C1 attempted to enter the

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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: 08/31/2022

NARRATIVE

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(Cont from 809C)

garage/office that should be a restricted area for C1. Several times throughout the visit C1 would “burst” into the office with no staff immediately following C1. The assigned 3:1 staff would appear shortly after C1 and usually through a different entry than C1.
On 07/15/22 there were only 2 staff supervising C1 and they allowed C1 to get into LPA Smith’s personal space and grabbed files from the desk. Concerns were addressed and the staff was informed by the LPA that they were expected to provide the 3:1 supervision accordingly. Improper supervision of C1 were observed on 08/19/22 and 08/24/22. These concerns were expressed to the facility staff in addition to the health and safety of staff and visitors. On 08/24/22 LPA Smith, LPM Margaryan, Quality Assurance Manager (QAM) Venues Rodriguez-Khodabasi and Service Coordinator (SC) Cristina Perez observed C1 accessing the staff’s workspace freely, and C1 becoming very upset when prevented from entering and yelling at the staff not to lock the door. On or around 5:30pm, C1 walked into the garage/office again and was exhibiting uncontrollable and aggressive behavior (Yelling, screaming, making verbal threats, cursing, moving his hands, knocking over Licensing staff equipment, and throwing water bottle). CCL and NLARC staff were unable to complete visit reports and had to leave the facility to deescalate and avoid possible physical aggression by C1. During this visit LPA Smith discussed Licensing reports initiated at the facility and will provide copies of the reports for signature.

The Licensee representatives were notified that further noncompliance with the Title 22 Regulations will result other actions as it deems necessary by the Department. The Licensee was informed that:

1.The Department, at its discretion, will make unannounced case management visits to monitor the licensee’s compliance.
2. The Department is not deprived of its authority to take appropriate formal legal action under the Health and Safety Code when such action is deemed necessary by the Director.

Exit interview was conducted and a copy of report emailed for signatures

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC809 (FAS) - (06/04)

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