<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 08/24/2022
Date Signed: 09/07/2022 10:44:02 AM

Document Has Been Signed on 09/07/2022 10:44 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 HOMEFACILITY NUMBER:
197610235
ADMINISTRATOR:LABEODAN, TAYOFACILITY TYPE:
737
ADDRESS:35158 WYSE ROADTELEPHONE:
(626) 500-1430
CITY:SANTA CLARITASTATE: CAZIP CODE:
91390
CAPACITY: 4CENSUS: 1DATE:
08/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Jones OdogwuTIME COMPLETED:
06:00 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
This Case management-deficiency visit was conducted in conjunction with the Case management- Incident follow up visit to address the deficiencies noted at the facility that were unrelated to an incident investigation.

On 8/24/2022 Licensing Program Analyst (LPA) Tihesha Smith, Licensing Program Manager (LPM) Naira Margaryan, along with Quality Assurance Manager (QAM) Venus Rodriguez-Khorasani, and Service Coordinator Cristina Perez from North Los Angeles County Regional Center (NLACRC) conducted a joint case management visit to the facility.

LPA Smith was greeted by Staff Jones Odogwu and the purpose of the visit was explained.

During the visit the following was observed:

PHYSICAL PLANT: The garage had a broken lock on the door, a broken door frame, and broken cabinets. The hallway walls and doors were stained and unkept.

CLEANING SUPPLIES: Cleaning supplies were accessible in the garage and laundry room. All cleaning solutions was removed and placed in an inaccessible closet that was also the medication closet.

FOOD SERVICE: The facility did not have a supply of nonperishable foods for a minimum of one week or fresh perishable food for a minimum of two days on the premises. There was rotten food in the refrigerator.

STAFFING: During the visit there was four staff on shift in which five should be on shift. The fifth staff was shopping and servicing the facility van. When asked who the lead was the staff was not sure. Staff 3 (S3) stated they were lead, but they had only been working at the facility for approximately three weeks. During interviews staff had limit knowledge about their roles and responsibilities for the day. Administrator confirmed that there was a high turnover of personnel, and it impacted the facility.

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)
Page: 1 of 6
Document Has Been Signed on 09/07/2022 10:44 AM - It Cannot Be Edited


Created By: Tihesha Smith On 08/29/2022 at 09:16 AM
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: WYSE HOME
FACILITY NUMBER: 197610235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
80065(a)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Administrator along with Elwyn QA have been conducting interviews for possible candidates for employment specifically for the Wyse home. Submit detailed report of efforts. POC date by:09/15/22
8
9
10
11
12
13
14
The Licensee did not ensure that the staff are competent to provide services to meet individual need of the client.This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
09/15/2022
Section Cited
CCR80065(f)

1
2
3
4
5
6
7
Personnel Requirements. (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill appropriate to the job assigned and as evidenced by safe and effective job performance.
1
2
3
4
5
6
7
Administrator/staff will receive training. Submit detailed agenda regarding the training and name of trainer as well as list of all staff attending the training. POC date by:09/15/22
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
The Licensee did not ensure that facility staff assisting C1 had appropriate qualification and training to control C1. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/07/2022 10:44 AM - It Cannot Be Edited


Created By: Tihesha Smith On 08/30/2022 at 10:55 AM
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: WYSE HOME
FACILITY NUMBER: 197610235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited
CCR
80075(f)

1
2
3
4
5
6
7
Health Related Services (f). Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator/staff will receive vendor training. Submit detailed agenda regarding the training and name of trainer as well as list of all staff attending the training. POC date by:09/02/22
8
9
10
11
12
13
14
Licensee did not ensure that the staff working at the facility has current first aid certificates. First Aid certificates for the few staff were expired. This poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type A
09/02/2022
Section Cited
CCR85165(b)(2)

1
2
3
4
5
6
7
Emergency Intervention Staff Training (b) Staff who use, participate in, approve, or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for successfully completing the training.

1
2
3
4
5
6
7
Administrator/staff will receive vendor training. Submit detailed agenda regarding the training and name of trainer as well as list of all staff attending the training. POC date by:09/02/22
8
9
10
11
12
13
14
(2) Staff shall maintain valid certification. This requirement is not met as evidenced by:The Licensee did not ensure that facility staff maintain required certificate identifying participation to the emergency intervention training. This poses a potential risk to the personal rights of the clients in care.
8
9
10
11
12
13
14
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/07/2022 10:44 AM - It Cannot Be Edited


Created By: Tihesha Smith On 08/30/2022 at 12:00 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: WYSE HOME
FACILITY NUMBER: 197610235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited
CCR
85076(d)(1)

1
2
3
4
5
6
7
Food Service (d)The licensee shall meet the following food supply and storage requirements: (1) Supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by
1
2
3
4
5
6
7
Administrator will ensure food supply is adequate for clients needs.Submit proof food supply has been replenished and document how future food issues will be prevented. POC date by:09/02/22
8
9
10
11
12
13
14
Licensee did not ensure to maintain appropriate quantity and variety of food in supply. There was very little fresh food in the refrigerator. This poses potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
09/15/2022
Section Cited
CCR80075(b)(5)(B)

1
2
3
4
5
6
7
Health Related Services (b) Clients shall be assisted as needed with self-
administration of prescription and nonprescription medications. (5)(B) Once ordered by the physician the medication is given according to the physician's directions.
1
2
3
4
5
6
7
Administrator will ensure staff will receive medication adminstration/documentation training and reporting requirements. Submit detailed agenda regarding the training and name of trainer as well as list of all staff attending the training. POC Date By:09/15/22
8
9
10
11
12
13
14
This requirement is not met as evidenced by: License did not ensure that facility C1’s medication was dispensed according to doctor’s direction. C1’s morning medications were missed and no documentation explaining the reasons. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/07/2022 10:44 AM - It Cannot Be Edited


Created By: Tihesha Smith On 08/30/2022 at 12:31 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: WYSE HOME
FACILITY NUMBER: 197610235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
80064(2)

1
2
3
4
5
6
7
Administrator - Qualifications and Duties. The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will continue to adhere to all needs and service plans by providing the necessary training to keep the administrator and staff up to date with the latest information. Submit detailed agenda of required training. POC date by:09/15/22
8
9
10
11
12
13
14
The Licensee did not ensure to hire qualified personnel that could assist to prevent/de-escalate C1’s behaviors. The 3 staff assisting C1 were unable to redirect or de-escalate C1’s behavior. This poses a potential health and safety risk to client in care.
8
9
10
11
12
13
14
Type B
09/15/2022
Section Cited
CCR80066(a)

1
2
3
4
5
6
7
Personnel Records. (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will ensure personnel records are maintained and current by conducting records review on all personnel files and updating each file to bring into compliance. Submit detailed agenda regarding record review status/timeline. POC date by:09/15/22
8
9
10
11
12
13
14
The Licensee did not ensure to maintain personal records for each staff working at the facility. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
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
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
26
27
28
29
30
31
32
(Cont from 809)

PERSONNEL FILES: At the time of the visit the staff records were reviewed and were incomplete. 11 out of 22 staff records did not have required training hours, First Aid, CPR, and CPI certificates. Representatives for NLACRC informed the LPA they would provide a list of training topics that were missing and/or incomplete.

MEDICATIONS: During the visit the client’s Medication Administration Records revealed that the client’s AM medications were missing signatures for 8/15/2022, 8/16/2022, 8/19/2022 and 8/24/2022. When LPA asked the staff, they stated that the client wanted to sleep. There was no documentation to support this statement and no incident reports were submitted to CCL.

SUPERVISON: During the visit it was observed on several occasions that the staff was unable to redirect the client. Client was allowed to “bust” into the office with no staff in sight and interrupt the visit. At 5:30pm client walked into the garage and was exhibiting uncontrollable behaviors (yelling, screaming, making verbal threats, cursing, moving their hands, knocking over LPA’s equipment, and throwing a water bottle). LPA expressed their concern about the health and safety of CCL, NLACRC and facility staff.

Facility was observed to be non-compliant to Title 22 Regulations. Citations were issued and recorded on LIC809D.

Client’s behavior posed an imminent threat to CCL and NLACRC personnel. To avoid further complications, the representatives left the facility and informed the staff that a copy of the report will be provided to the Administrator via email for a 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)
Page: 6 of 6