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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610130
Report Date: 11/29/2022
Date Signed: 02/16/2023 06:11:47 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
09/21/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220921113436
FACILITY NAME:REM CALIFORNIA LLC - BAIRDFACILITY NUMBER:
197610130
ADMINISTRATOR:FREEMAN, ELIZABETHFACILITY TYPE:
735
ADDRESS:10426 BAIRD AVETELEPHONE:
(818) 363-3333
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:4CENSUS: DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Modupe Ayeni DunlapTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff kicked resident while in care resulting in injury.
INVESTIGATION FINDINGS:
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***This is an amended report to correct errors no changes to the findings***

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 12:45 pm to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit.
During initial visit, on 9/22/2022, LPA Smith conducted tour of physical plant, conducted interviews with administrator and staff from 9:45 AM – 1045 AM and obtained copies of documents relevant to the investigation.
LPA Tihesha Smith made two subsequent visits to this facility on 10/25/22 and 11/01/22. On 10/25/2022, LPA interviewed resident from 1:20-1:45 pm and on 11/01/2022 LPA interviewed staff from 3:55 pm- 4:15 pm.
Regarding the allegation: Staff kicked resident while in care resulting in injury.
It was alleged that Staff #3 (S3) kicked Resident one (R1) while in care resulting in injury. Interviews with Staff revealed that R1 was having a behavior episode after being told that their desired drink was not available to include in their packed lunch.
(Cont to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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-20220921113436
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: REM CALIFORNIA LLC - BAIRD
FACILITY NUMBER: 197610130
VISIT DATE: 11/29/2022
NARRATIVE
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(Cont from 9099)

During behavior episode R1 yelled at S3, pushed items on kitchen counter onto the floor then ran into dining area and grabbed the fan. As R1 grabbed fan, R1 tripped and fell with the fan and was injured. Staff denied kicking R1. They try to assist and R1 refused assistance from staff.

LPA Smith interview with R1 revealed that R1 fell because of wearing boots with heels and tripped over fan cord. R1 also revealed they bruise easily. R1 states S3 did not kick them and didn’t mean to wish S3 would die. R1 stated they apologized for their behavior already and R1 also stated that S3 is kind, nice and works hard.

Based on the interviews during this and previous licensing visits there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.



No health and safety hazard is noted during this visit.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2