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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610361
Report Date: 03/07/2025
Date Signed: 03/07/2025 12:53:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/17/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240517125219
FACILITY NAME:LIBERTY RESIDENTIAL FACILITYFACILITY NUMBER:
197610361
ADMINISTRATOR:TILLMAN, WILDA WFACILITY TYPE:
735
ADDRESS:3330 RACQUET LANETELEPHONE:
(661) 916-9090
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:4CENSUS: 3DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wilda Tillman TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident had access to medication resulting in hospitalization
Staff does not ensure resident is administered medications.
Staff does not allow resident's visitations.
Staff does not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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On 3/07/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Licensee Wilda Tillman. LPA explained the purpose of this visit was to deliver the findings.

The investigation consisted of the following: On 5/23/2024, LPA Spaeth initiated a complaint investigation. At 10:00 am until 10:15 am, LPA reviewed clients’ files and client medication records. LPA also interviewed three (3) out of four (4) clients and five (5) out of nine (9) staff members. LPA received a copy of the client roster, staff work schedule, staff phone numbers, and client documentation.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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 2
Control Number 31-AS-20240517125219
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LIBERTY RESIDENTIAL FACILITY
FACILITY NUMBER: 197610361
VISIT DATE: 03/07/2025
NARRATIVE
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Regarding the allegation: A client had access to medication resulting in hospitalization. It’s alleged facility staff did not contact the authorized representative regarding an incident that caused harm to a client. The three (C1, C2, C4) clients confirmed this did not occur. C3 was unavailable. Five (S1-S5) staff members confirmed this did not occur at the facility.

Regarding the allegation: Staff does not ensure a client is administered medications. Its alleged staff have informed a client they do not need their medication and they can refuse their medication. Three clients (C1, C2, C4) stated staff have never made these statements. A client confirmed they refused to take a medication due to the side effects but their doctor and family members are aware of their choice. C3 was unavailable. Five (S1-S5) staff members denied the allegation. LPA viewed four clients’ medication logs and observed medications were given to three clients (C2-C4). A review of a client’s (C1) medication logs revealed they refused their medication on 3/06/2025.

Regarding the allegation: Staff do not allow client’s visitations. It’s alleged clients cannot have visitors at the facility. Three clients (C1, C2, C4) stated they have family members visit all the time. C3 was unavailable. Five (S1-S5) staff members denied the allegation.

Regarding the allegation: Staff does not safeguard resident's personal belongings. It’s alleged staff have taken a client to a pawn shop to pawn their personal items. Three clients (C1, C2, C4) stated this has never occurred. C3 was unavailable. Five (S1-S5) staff members denied the allegation.

Based upon interviews and review of the clients’ records, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2