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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610130
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:19:40 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
06/28/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240628090950
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:
07/03/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Idris DanesiTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff handled client in a rough manner
Facility staff used client to assist with lifting another client
Facility staff did not assist client with medical appointments as needed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived at the facility and were granted access by staff. REM Director Idris Danesi was present at the facility and explained the reason for the visit. LPA requested copies of pertinent information which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Individual Program Plan (IPP), etc., relevant to the investigation. LPA conducted a physical plant tour, to ensure health and safety of the clients are protected and physical plant is in compliance with Title 22 Regulations

Allegation:Facility staff handled client in a rough manner
It was alleged that S1 wrestled and pushed C1 against a wall. Interview with C1 revealed that S1 held C1's right wrist, bundle up, pushed C1 against the wall. C1 stated that it was the wrong procedure to take in a behavior crisis and S1 was suspended immediately after the incident.
(Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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 4
Control Number 31-AS-20240628090950
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: 07/03/2024
NARRATIVE
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Interview with S2 confirmed the allegation stating that S1 did pushed C1 against the wall. Based on information obtained the allegation deemed Substantiated at this time.

Allegation: Facility staff used client to assist with lifting another client
It was alleged that C1 assisted staff with lifting C2 during the night shift. It was revealed that there was only one staff is working during night shifts. On 06/18/24 CCL received an incident report reporting a fall. C2 fell on the floor S4 was unable to lift C2 off the floor and asked C1 for assistance. Interview with S2 confirmed the allegation and stated that they will schedule 2 staff at night shift and hire new staff to meet clients needs. Based on Special Incident Report and interviews the allegation deemed Substantiated at this time.

Allegation: Facility staff did not assist client with medical appointments as needed
It was alleged that facility staff asked C1 to reschedule medical appointments when appointments conflicted with C2's medical appointments or day program hours. Interview with S3 denied the allegation. However, it was revealed that C1 gets agitated and refuses to use another facility vehicle or transportation when C2 uses the facility van for medical appointments or day program. Thus, medical appointments were rescheduled due to the conflict. Based on information obtained the allegation deemed Substantiated at this time.

Exit interview conducted. Citations issued appeal of rights given and a copy of this report delivered.

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SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20240628090950
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: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2024
Section Cited
CCR
87468(a)(1)
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Personal Rights:Residents in all residential care facilities for the elderly shall have all of the following personal rights-To be accorded dignity in their personal relationships with staff, residents, and other persons.
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S1 has been removed from the facility and is currently not working in the facility. Administrator will submit a plan to address this section of the regulations. The plan must include the vendor number, training topic and attendance log. Training and certification must be submitted to the licensing agency by July 17,2024.
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This requirement was not met as evidenced by: Based on interviews conducted and SIR submitted, it was confirmed that S1 pushed and wrestle C1. This posed an immediate health and safety risk to all clients in care
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Type A
07/04/2024
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Administrator will provide an LIC500 showing adequate staff coverage from today until 07/17/24. Administrator will ensure a new staff member will be hired by July 17,2024
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This requirement was not met as evidenced by: Based on interviews conducted and SIR submitted, it was confirmed that C1 assisted staff to lift C2 from the floor. This posed an immediate health and safety risk to all clients in care
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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: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4