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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610235
Report Date: 08/19/2022
Date Signed: 09/07/2022 12:08:58 PM

Document Has Been Signed on 09/07/2022 12:08 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:
08/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:David AvilaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted a joint Case Management-Incident visit to this facility with representatives from North Los Angeles County Regional Center (NLACRC) Venus Rodriguez-Khorasani and Royce Remelius.

LPA Smith met with the Administrator and explained that this visit was conducted to follow up and investigate an incident reported to the Community Care Licensing Office (CCLD) on 07/19/22.

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

During this visit from 11:15am and 1:00pm, LPA Smith requested and reviewed facility records relevant to the investigation. Between 12:50pm and 3:15pm LPA Smith spoke with the administrator and staff.

Based on the information gathered during this visit, it was concluded that Further investigation is required to investigate an incident.

Exit interview conducted. Copy of this report emailed for signature.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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