197610130-4-18-2023-31-AS-EMIR-CTHUVE-20230707155500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610130
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:30:09 PM

Unsubstantiated

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
04/12/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230412162934

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: 4	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Elizabeth Freemen-Adminstrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care

INVESTIGATION FINDINGS:

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On 04/18 Licensing Program Analysts (LPAs) Agard and Agban conducted an initial complaint investigation at the above facility to address the following allegation. LPAs Agban and Agard were met by Elizabeth Freeman, Administrator. LPAs explained the purpose of this visit was to gather information, conduct interviews and deliver findings for this complaint.

The investigation consisted of the following: on 4/18/2023 LPAs initiated an investigation. LPA toured the physical plant and requested records. The following records were requested: 1) staff roster, 2) client roster, 3) Individual Service Plan for C1, 4) Physician Report for C1, 5) Functional Capability Assessment, 6) Daily body check, 7) C1 Face Sheet, 8) Daily Summary Notes, 9) Hospital Discharge document, and 10) Special Incident Report.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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-20230412162934

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: 04/18/2023

NARRATIVE

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The investigation revealed the following: Regarding the allegation…. Resident sustained an unexplained injury while in care. It’s alleged a client had unexplained bruises from an unknown injury. LPAs interviewed 2 out of 8 staff in total. 2 out of 2 denied the allegation. S1 states that the staff called them when the caregiver saw a blister on C1’s finger with fluid coming out of it. Caregiver took C1 to Urgent Care and then to Holy Cross Hospital. S1 stated that C1 was on medications that caused them issues with their immune system. Specifically, a medication that caused the client to develop redness and bruising. This medication has been stopped and no other client has been physically aggressive toward C1. S2 states, they never observed anyone hit C1 not even another client. LPAs interviewed a witness. W1 stated that C1 went to the hospital for an unrelated reason and noticed that C1 had swelling on their index finger, bruising, and peeling skin. W1 suspected C1 was having an allergic reaction to a new medication. C1 has no history of redness or bruising, per W1. W1 also mentioned that there’s no other reason for suspicion. LPA interviewed W2, and W2 states, “The facility takes good care of C1, there are no complaints or issues from them.” LPA attempted to interview 4 out of 4 clients in care but was unable to due to the client’s cognitive ability.

During a record review and observation, LPAs observed the client to have no bruising. The caregiver conducted a body check of the client’s extremities and observed no bruises. LPAs reviewed body check forms from April 1^st to the present. Notes state that there are no bruises prior to April 11, 2023. Per the facility, C1 started a new medication a month ago which cause them redness and bruises. During hospitalization, the medication was discontinued because of other adverse effects it was having on C1.

Based on LPA’s Observation, record review, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted, and a copy of the report was given.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

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