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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610130
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:34:22 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
10/23/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20241023133708
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: 2DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jonathan WattsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not treat resident(s) with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegation. LPA arrived at the facility and was granted access by staff. Administrator Jonathan Watts was present at the facility and explained the reason for the visit. LPA requested copies of pertinent information which include, but not limited to Staff Roster, Clients Roster, Staff schedule, 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: Staff do not treat resident(s) with dignity and respect
It was alleged that Staff 1 (S1) was pushing a box and Client 1(C1) asked them to stop. S1 didn’t stop which triggered C1. C1 banged their head into the wall, kicked the cabinet, and punched the wall due to staff ignorance. LPA interviewed 2 out of 4 staff members and 1 out of 2 clients.
(Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 3
Control Number 31-AS-20241023133708
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: 10/30/2024
NARRATIVE
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Interview with Staff 2(S2) revealed that S1 was relocating sharp objects box from one cabinet to another as the new cabinet lock was more secure. C1 expressed agitation as they like consistency. S1 walked away and C1 had a behavior. Per S2, C1's behavior consisted of aggression, property destruction, and self-injury behavior. S2 mentioned that C1 was offered to go to the hospital but C1 refused. LPA conducted a file review and obtained a copy of the incident's Special Incident Report (SIR). Interview with C1 revealed that S1's ignorance was intentional. S1 continued relocating the box after C1 told S1 to stop which triggered C1. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted, citation issued, and copy of this report signed and delivered.



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

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241023133708
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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights (a)...each client shall have personal rights which include,...(1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by:
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Administrator will submit a plan to address this section of the regulations. The plan must include the training topic, vendor number,and attendance log. Training and certification must be submitted to the licensing agency by 11/22/24.
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Based on SIR and interviews S1 ignored C1's request which led C1 to self injuries and aggression. This posses an immediate health and safety risk to 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: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3