197610132-10-6-2021-31-AS-NGID-C8LV6K-20211109150941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610132
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:39:52 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
09/30/2021 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20210930120008

FACILITY NAME:	REM CALIFORNIA LLC - 27TH STREET		FACILITY NUMBER:	197610132
ADMINISTRATOR:	DAY, DANSHELLE		FACILITY TYPE:	735
ADDRESS:	43778 27TH STREET WEST		TELEPHONE:	(818) 363-3333
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	4	CENSUS: 4	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Moshood Ibrahim		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent a physical altercation between residents resulting in injuries.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Angela Panushkina and Melissa Ruiz met with the Administrator, Moshood Ibrahim at 10:30 am for a complaint investigation. Entrance interview conducted.

At 10:40 am LPAs requested LIC500, client roster and files. File review consisted of but was not limited to review of the physician report, resident care plans, relevant logs, etc. Review concluded at 11:50 am.
LPAs interviewed two (2) out of four (4) residents from 12:00 pm to 1:00 pm. LPAs were unable to interview other residents as they were not at the facility at this time. At 1:00 pm, LPAs conducted a physical plant tour and noted no health and safety issues or concerns.

LPAs conducted interviews of two (2) staff members, and the Administrator.
It is alleged that staff did not prevent a physical altercation between residents resulting in injuries.
Interviews with two (2) out of four (4) residents revealed that they have witnessed a resident (R1) try to get physical with staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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-20210930120008

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 - 27TH STREET	FACILITY NUMBER: 197610132
	VISIT DATE: 10/06/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Both residents stated R1 has not gotten physical with other residents. In addition, residents also stated that when physical altercations occur, they trust and feel confident staff is well trained to prevent any physical altercations.

Interviews with two (2) staff and the Administrator indicate that staff feel confident that they are well trained. Staff stated they have each received crisis prevention training from CPI (crisis prevention institute) valid for two (2) years and receiving monthly refresher courses from Board Certified Behavior Analysts (BCBA). LPAs obtained copies of training certifications and a daily behavior log for R1.

Based on documents obtained and interviews conducted among staff and residents, the allegation that staff did not prevent a physical altercation between residents resulting in injuries is unsubstantiated at this time.

No deficiency issued. Exit interview conducted. Report delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2