197610130-1-10-2025-31-AS-EMIR-DEEVYK-20250303155116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610130
Report Date: 12/18/2024
Date Signed: 01/10/2025 02:57:53 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
08/11/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230811124356

FACILITY NAME:	REM CALIFORNIA LLC - BAIRD		FACILITY NUMBER:	197610130
ADMINISTRATOR:	FREEMAN, ELIZABETH		FACILITY TYPE:	735
ADDRESS:	10426 BAIRD AVE		TELEPHONE:	(818) 363-3333
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	4	CENSUS: 1	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kenda Comstock		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not adequately supervise residents resulting in a resident being physically assaulted by another resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Mariana Agban and Nadia Shahbazian conducted a subsequent complaint investigation. Upon arrival, LPAs met with Program Director Kenda Comstock and the Administrator, and the purpose of the visit was explained. LPAs conducted a physical plant tour, to ensure the health and safety of the residents were protected and the physical plant was in compliance with Title 22 Regulations. Today's investigation consisted of additional interviews and obtaining additional documents.

Allegation: Staff did not adequately supervise residents resulting in a resident being physically assaulted by another resident while in care.

It was alleged that Staff did not adequately supervise residents resulting in a resident being physically assaulted by another resident while in care. Interviews and records review indicated during the physical altercation between R1 and R2 both R1 and R2 each required a 1:1 Staff to supervise each of them due to their behavioral needs. (Continue on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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-20230811124356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - BAIRD	FACILITY NUMBER: 197610130
	VISIT DATE: 12/18/2024

NARRATIVE

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The required 1:1 staff (24/7) for R1 had not been appointed or scheduled. There were three staff on duty at the facility at the time of the incident. The census at the time of the incident was 3. Per the Special Incident Report dated 08/09/2023, submitted by the Administrator, R1 had struck and bitten R2.
Staff on duty S1, attempted to redirect R1 by advising R1 to go to the bedroom. Despite the attempt(s) at redirection by staff 1 (S1) , R1 sustained two red marks on R1’s right leg/knee, and R1’s left wrist was observed to have visible bite marks.

Information obtained during interviews confirmed that R1 had been admitted to the facility without completing a thorough and comprehensive preplacement appraisal and that a behavior plan had not been provided for the purpose of meeting the needs of R1.

Records review also revealed that facility staff did not complete and submit the required SOC 341 Report of Suspected Adult/Elder Abuse as a part of Assembly Bill 40(AB40) requirements.

Based on the information obtained the allegation that Staff did not adequately supervise residents resulting in a resident being physically assaulted by another resident while in care is deemed Substantiated. Exit interview conducted, citation issued , an immediate civil penalty assessed, appeal rights provided and copy of this signed and delivered. A simultaneous Case Management Visit was also conducted to address deficiencies that were identified during the complaint investigation but were not included in the original allegations.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230811124356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - BAIRD	FACILITY NUMBER: 197610130
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/19/2024 Section Cited CCR 85078(a)(1)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision: The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.	1 2 3 4 5 6 7	Within 24 hours, the Administrator will submit a plan to address this section of the regulation. Administrator will email LPA by the POC date. On 1/10/25 LPA asseed immediate $500 due to R1's injury
	8 9 10 11 12 13 14	Staff failed to provide adequate supervise to residents resulting in a resident being physically assaulted by another resident while in care. This posed an immediate health and safety risk to the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14		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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC9099 (FAS) - (06/04)

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