197609568-7-5-2023-31-AS-NGID-CV7MLD-20230830094209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609568
Report Date: 07/05/2023
Date Signed: 07/05/2023 03:51:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/29/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230629095937

FACILITY NAME:	BEWISE HOME		FACILITY NUMBER:	197609568
ADMINISTRATOR:	OKONKWO, CHINWEIKE		FACILITY TYPE:	740
ADDRESS:	22214 VANOWEN STREET		TELEPHONE:	(818) 300-4994
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 3	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Rachel Akampa, Staff		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not prevent resident from wandering from facility
Staff did not notify authorities that resident was missing

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angela Panushkina and Michael Cava conducted the 10 day investigation visit to the facility regarding the above allegations. Upon arrival LPAs met with Staff #1 who granted access to the facility. Administrator arrived shortly after, and LPAs explained the reason for the visit.

During course of the investigation, interviews and record review were made. LPAs requested staff and residents roster. At approximately 11:20am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. At 11:30am, LPAs requested copies of pertinent information which include, but not limited to R1's History and Physical reports, Hospital Discharge, etc., relevant to the investigation. Between 12:00pm – 1:00pm, LPAs interviewed the Administrator, one (1) staff and attempted to conduct an interview with three (3) residents.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230629095937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BEWISE HOME	FACILITY NUMBER: 197609568
	VISIT DATE: 07/05/2023

NARRATIVE

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Allegation: Staff did not prevent resident from wandering from facility

During the course of this investigation, LPAs interviewed the Administrator, S1 and reviewed R1's file and obtained relevant documentation pertaining to this allegation. Interview with the Administrator and S1 revealed R1 moved to this facility in November 2022. Interviews with staff revealed that R1 could not leave the facility unassisted due to head trauma. LPAs were also informed that R1 did not have a history nor showed signs of wondering out. Moreover, interviews with the Administrator and S1 confirmed that on 06/25/23 around 12:30pm, R1 went missing. Staff did not realize R1 was missing until 1:00pm. Once staff realized R1 was not at the facility, staff conducted a search within this facility to locate R1. The search was unsuccessful as R1 was nowhere within this facility. In addition, LPAs were informed that an incident report was submitted to LA County at 11:30pm, and on 06/26/23, the Administrator contacted the Police Department to file a Missing Person's Report. Lastly, LPAs were informed that on 06/28/23 at 11:45am, S1 observed R1 walking across the street from the facility. S1 immediately assisted R1 back to the facility. Although, R1 refused to go to an Emergency Room, 911 was requested by the Administrator and R1 was taken to the hospital and released on a following morning (06/29/23). Based on information obtained from records review and interviews, the above allegation is deemed Substantiated.

Allegation: Staff did not notify authorities that resident was missing

It was reported that on 06/25/23, R1 went missing from the facility and did not return until 06/28/23. Although, interview with the Administrator revealed that the LA County and the Police Department were immediately notified regarding R1's elopement, LPA reviewed Incident Reports submitted to the Regional Office and did not observe a copy of R1's incident on file. Based on interviews and record reviews, the above allegation is deemed Substantiated.

Deficiencies documented on 9099D.

Exit interview conducted, appeal rights explained and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230629095937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: BEWISE HOME	FACILITY NUMBER: 197609568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/12/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to provide in-service training to all staff to address this section of the Regulation. Copy of training will be submitted to LPA
	8 9 10 11 12 13 14	Based on the investigation, the licensee did not comply with the section cited above. Administrator admitted that R1 can't leave the facility unassisted, but on 06/25/23 R1 went missing which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 07/12/2023 Section Cited CCR 87211(a)(D)	1 2 3 4 5 6 7	Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare.. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	During the visit the Administrator provided the LPA with a copy on Incident Report that was emailed to the County on 06/29/23. No further correction is needed.
	8 9 10 11 12 13 14	Based on record reviews, the licensee did not comply with the section cited above. by not submitting R1's incident report to the Regional Office, which poses a potential health and safety risk to residents 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.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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