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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610235
Report Date: 02/05/2025
Date Signed: 02/05/2025 01:18:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/05/2024 and conducted by Evaluator Angelica Segovia
COMPLAINT CONTROL NUMBER: 31-AS-20241205144811
FACILITY NAME:WYSE HOMEFACILITY NUMBER:
197610235
ADMINISTRATOR:DAVIS, LA QUENCIAFACILITY TYPE:
737
ADDRESS:35158 WYSE ROADTELEPHONE:
(626) 500-1430
CITY:SANTA CLARITASTATE: CAZIP CODE:
91390
CAPACITY:4CENSUS: 2DATE:
02/05/2025
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:LaQuencia Davis-AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not provide services to residents as identified in their Needs and Services plan.
Staff did not adhere to residents' Admission Agreements.
INVESTIGATION FINDINGS:
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On 2/5/25 at around 10:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations.
LPAs met with Administrator LaQuencia Davis and explained the reason for the visit.

It was alleged that staff did not provide services to residents stated within their Needs and Service Plan as well as Admission Agreement.

To investigate the allegations, LPAs asked for census, Staff, and Resident Roaster. LPAs also requested pertinent documents relevant to the investigation at approximately 10:30AM. LPAs conducted record review between 11:30AM to 12:30PM. Record Review revealed that on 11/12/24 an unannounced Semi-Annual audit was conducted by North Los Angeles Regional Center (NLARC) staff and during their audit, they found out that the facitlity was missing and/or incomplete documentation on the services required by Client #1 (C1) and Client #2 (C2) resulting to deficiency under Title 17. (Continue to LIC 9099-C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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-20241205144811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WYSE HOME
FACILITY NUMBER: 197610235
VISIT DATE: 02/05/2025
NARRATIVE
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Corrective Action Plan (CAP) was issued to the facility on 12/2/24.

LPAs’ interview with the Administrator today at 11:00 AM, revealed that they have complied with the CAP and provided the letter by the NLARC dated 01/27/24 wherein the facility was cleared.

Based on record reviews and interviews there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Deficiencies were cited. (Refer to LIC 9099-D).

No other health and safety hazards noted during the visit. Exist interview conducted. Appeals rights given and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241205144811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYSE HOME
FACILITY NUMBER: 197610235
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2025
Section Cited
CCR
89968.2(b)
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The licensee shall ensure each client's Individual Behavior Support Plan include all the requirements established in Title 17, Division 2, Chapter 3.

This requirement is not met as evidenced by:
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Administrator provided the proof of compliace through a case closure letter issued to the facility by NLARC.

Cleared during visit.
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Based on interview and record review, the licensee did not abide by the above regulation which poses a potiental personal rights and 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3