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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610132
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:07:08 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
05/10/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230510171655
FACILITY NAME:REM CALIFORNIA LLC - 27TH STREETFACILITY NUMBER:
197610132
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:43778 27TH STREET WESTTELEPHONE:
(661) 726-0663
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Moshood IbrahimTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff mistreated a resident in care.
INVESTIGATION FINDINGS:
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On 05/17/2023 at 9:48 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced complaint visit. LPA was greeted by staff #2 (S2) and granted access. S2 stated three out of the four clients were present at the facility. Client #1 (C1) was at day program. LPA met with Administrator, Moshood Ibrahim and LPA explained the purpose of the visit. Entrance interview conducted.

From 9:53 am to 10:30 a.m. LPA conducted interviews with the Administrator, staff #1 (S1), S2, Staff #3 (S3) and Staff #4 (S4). At 10:30 a.m. LPA obtained and reviewed documents relevant to this investigation. At 10:35 a.m. LPA conducted a physical plant tour of the facility and conducted interviews with clients along the way. LPA interviewed client #2 (C2), client #3 (C3) and client #4 (C4). At approximately 2:35 p.m. LPA conducted an interview with C1 and at 2:47 p.m. LPA conducted an interview with North Los Angeles County Regional Center Service Coordinator (SC) for C1.

(LIC9099-C Continued on next page)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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-20230510171655
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 - 27TH STREET
FACILITY NUMBER: 197610132
VISIT DATE: 05/17/2023
NARRATIVE
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(LIC9099-C Continued)

Allegation: Staff mistreated a resident in care.
It is alleged a client is being mistreated by staff and in particular was hit in the hand by a staff member. To investigate the allegation, LPA conducted interviews with the Administrator, four (4) out of four (4) clients and four (4) staff that worked in the time frame mentioned in this allegation. In regards to being mistreated and hit in the hand by a staff, four (4) out of four (4) clients revealed staff do not mistreat them or have ever hit them. Additionally, no staff have witnessed or heard of any staff mistreating clients. LPA reviewed Special Incident Report (SIR) for 05/08/2023, SIR revealed C1 "attacked" staff and staff blocked client and tired to redirect. LPA's interview with clients and staff revealed C1 was upset and had an episode of aggression. C1 reveled they were not hit in the hand but staff member held their hand and it hurt. C1 went on to explain they do not believe the staff member did it on purpose and they believe the staff member was trying to keep C1 from self harming or hitting the staff member. Clients and staff corroborate C1 was the aggressor and will "attack" staff when upset. Interview with the Administrator corroborates staff is trained to use Crisis Prevention Institute (CPI) strategies to block, evade and to redirect clients when they are having an episode of aggression. Based on interviews conducted, there is insufficient evidence to support the allegation that staff mistreated a resident in care. Therefore, the allegation is Unsubstantiated. Exit interview conducted, a copy of this report was signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2