197609704-7-14-2023-31-AS-NMAN-D58NRR-20240513104159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609704
Report Date: 07/14/2023
Date Signed: 07/14/2023 05:30:22 PM

Unsubstantiated

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
04/24/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230424133758

FACILITY NAME:	SAFE LAUREL LLC		FACILITY NUMBER:	197609704
ADMINISTRATOR:	GBOYEGA AKINBOLA		FACILITY TYPE:	735
ADDRESS:	16300 VINTAGE ST		TELEPHONE:	(818) 489-1218
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	4	CENSUS: 3	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Cheryl Perkins		TIME COMPLETED:	05:35 PM

ALLEGATION(S):

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Staff hit client in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at approximately 10:35 am. LPA Smith rang the doorbell and knocked on front door but there was no answer. LPA called the facility and left a voice message; LPA then contacted LPM Troy Agard at approximately 11:08 am to inform manager. During call with LPM, the licensee called LPA Smith. Licensee revealed staff and residents are on outing but will contact the Administrator. The administrator arrived at approximately 11:37 am.

During initial visit on,04/27/23, LPA Smith conducted tour of physical plant at approximately 11:32 am, conducted interviews at approximately 11:40 am and requested documents relevant to the investigation including but not limited to personnel Report and resident roster.

Staff hit client in care
It was alleged that Staff #1 (S1) hit Resident #1 (R1). LPA Smith reviewed facility records, conducted interviews with staff and residents, and requested copies of documents relevant to the investigation to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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-20230424133758

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: SAFE LAUREL LLC	FACILITY NUMBER: 197609704
	VISIT DATE: 07/14/2023

NARRATIVE

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(Cont from 9099)

to include but not limited to Physician report, Daily logs, and Resident Register from approximately 11:26 pm- 415 pm.

During interviews, S1 denied hitting R1. S1 revealed that they do not hit any residents in care. S1 revealed R1 was having a behavior episode and R1 hit them on the backside of hand/wrist area causing area to swell. S1 revealed R1 has a history of aggressive behaviors. S1 revealed they firmly told R1 not to hit them and firmly redirected him. Interview with R1 revealed that S1 did not hit them and that they hit S1. LPA Smith observed R1 person and did not observe any bruising or marks on R1. LPA Smith interview with six (6) out of six (6) staff reveal that R1 has behavior episodes and becomes physically and verbally aggressive towards staff and residents by yelling obscenities approaching them and waving fist to strike. Three (3) out of three (3) residents reveal staff has not hit them. Two (2) out of two (2) residents reveal R1 has chased them and tried to hit them and staff intervened.

A review of the Departments internal files shows that there are incident reports involving R1 being physically and/or verbally aggressive toward staff. R1 physician report revealed is diagnosed with impulse control disorder, is on antipsychotic medication to control behavior disorder. R1 also has a behavioral support plan to redirect them during challenging behavior episodes to include emotional outbursts, verbal aggression, self injurious behavior, property damage and physical aggression.

Based on interviews, record review, and LPA observation although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety hazard noted during this visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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