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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610130
Report Date: 02/14/2023
Date Signed: 09/29/2023 01:38:48 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
02/06/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230206095129
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: 3DATE:
02/14/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Elizabeth Freeman - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident multiple falls
INVESTIGATION FINDINGS:
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This report is an amendment of report dated 02/14/23 to rectify some errors. There is no changes in findings.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with administrator Elizabeth Freeman and explained the reason for the visit.

LPA conducted physical plant tour at 9:24 AM, requested copies of facility documents relevant to the investigation at 10:00 AM and interviewed the administrator and staff between 10:20 AM to 11:10 AM. Regarding the allegation that lack of supervision resulting in resident's multiple falls, it was alleged that Resident #1 (R1) fell twice in two (2) days while in the facility. LPA's record review at around 10:14 AM, revealed that on 08/30/22, R1 was prescribed a wheelchair on a PRN basis to be used outside of the facility like day program and outings due to R1's frequent falls at the day program. (continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
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-20230206095129
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: 02/14/2023
NARRATIVE
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(continued from LIC 9099)

LPA's interview with staff at 10:35 AM revealed that they observed that R1 was somehow getting weaker, so they started using the wheelchair even inside the facility beginning in mid-January. Further interview revealed that on 01/31/23 S1 was assisting R1 to transfer from the toilet to wheelchair in the bathroom, S1 locked the wheelchair from the back and about to pull R1 from the back of the wheelchair to situate R1 properly but R1 slid and fell instead. On 02/01/23, S1 assisted R1 to transfer from the wheelchair to the toilet but when R1 was already seated, S1 reached out for hygiene supply located in the drawer about two and a half (2 1/2”) feet away from R1 but R1 let go of the grab bar and fell sideways of the toilet. S1 staff was present and trying to help R1 on both occasion when R1 fell. LPA's interview with administrator at around 11:00 AM revealed that the facility immediately implemented a two (2) person assist to R1 after the second incident. LPA's record review confirmed that the two (2) persons assist to R1 was immediately implemented.

Based on the information gathered during today's visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2