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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:30:35 PM

Document Has Been Signed on 12/08/2022 12:30 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 HOMEFACILITY NUMBER:
197610235
ADMINISTRATOR:LABEODAN, TAYOFACILITY TYPE:
737
ADDRESS:35158 WYSE ROADTELEPHONE:
(626) 500-1430
CITY:SANTA CLARITASTATE: CAZIP CODE:
91390
CAPACITY: 4CENSUS: 1DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Jones OdogwuTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tihesha Smith conducted a Case Management- Incident visit. LPA met with staff and explained the reason for the visit.

On 10/25/22, the department received a self-reported incident report stating that Client #1 (C1) was given bedtime (PM) medications instead of morning (AM) medications. It was revealed that on 10/23/2022 Staff #1 (S1) did not follow medication administration protocol by not allowing Staff #2 (S2) to final check the collection of medication being administered before medication was given to the client. LPA clarified over the phone that C1 did not receive their full collection of prescribed morning (AM) medication and received the bedtime collection of medication instead.

Per administrator there have been no adverse effects on C1 as a result of the incident. The administrated revealed the doctor for C1 was contacted on 10/23/22 and informed of the incident. The clients’ doctor advised to monitor client and take to emergency room if vitals are not stable. Training was provided to all staff on medications policy, medication handling and three check system before administering. C1 has not seen a doctor as a result of this incident.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency was cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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Document Has Been Signed on 12/08/2022 12:30 PM - It Cannot Be Edited


Created By: Tihesha Smith On 12/08/2022 at 12:13 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2022
Section Cited
CCR
80075(b)5(B)

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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.
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Administrator will ensure that staff receive medication administration training and plan to address incorrect medications administered, missed medication and or C1’s refusal of medications. Submit detailed plan regarding the training and name of trainer as well as list of all staff attending the training. POC Date By:12/22/22
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This requirement is not met as evidenced by: License did not ensure that C1’s medication was dispensed according to doctor’s direction. C1’s bedtime medications were given instead of morning medications. This poses 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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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