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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610132
Report Date: 07/02/2024
Date Signed: 07/02/2024 10:07:00 AM

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
06/19/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230619155343
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:
07/02/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Shedrack Tetsola (staff)TIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident was injured by staff.
INVESTIGATION FINDINGS:
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On 07/02/24 Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent unannounced complaint visit to deliver findings for the above allegation. LPA arrived at the facility at 9:15 a.m. and was greeted by staff, Shedrack Tetsola. Shedrack called the Administrator, Moshood Ibrahim. LPA explained to administrator the purpose of the visit. Moshood is not able to meet LPA at the facility but LPA read the report to administrator by telephone and administrator designated Shedrack to sign todays report.

At 9:24 a.m. LPA conducted a physical plant tour to ensure the health and safety of the clients in care. No issues or concerns were observed.

Allegation: Resident was injured by staff.
It is alleged a client was thrown down to the ground by a staff member and sustained an injury. To investigate the allegation, an initial visit was conducted by LPA Rios on 06/20/23. (Cont. to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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-20230619155343
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: 07/02/2024
NARRATIVE
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On 06/20/23 LPA arrived around 10:26 a.m. LPA met with Staff 1 (S1) who contacted the administrator by telephone. LPA informed the Administrator, Moshood Ibrahim the purpose of the visit. LPA conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. No issues or concerns were observed. From 10:55 a.m. to 12:10 p.m. LPA reviewed and obtained documents relevant to the investigation. At approximately 11:29 a.m. LPA interviewed Administrator, Moshood via telephone. Client#1 (C1) arrived at 1:30 p.m.; by 2pm second shift staff arrived. LPA interviewed three (3) staff and four (4) out of four (4) clients from 12:10 p.m. to 2:30 p.m. Additional relevant documents to the investigation were requested from the administrator. On 04/10/24 LPA interviewed two (2) more staff present during the incident in question. During interviews for the investigation, three (3) staff and the administrator, confirmed that C1 will act out and has behavior issues of self-harm including hitting self and banging head. C1 will also attack the staff including kicking and spitting at staff. Four (4) Staff interviewed that were present during the incident in question stated that staff did not see any staff, throw C1 to the floor causing any harm including bruising, nor have any of them, thrown a client down to the floor. Staff state they have protected C1 from self-harm and attacks to staff from C1, staff with crisis prevention training have blocked or held C1 back to prevent injury. Three (3) of the four (4) clients interviewed about this allegation and incident deny seeing C1 being injured by staff, but confirm that C1 does act out, yelling, banging things, hitting herself and throwing things. C1 was the only client of the four, who states staff #2 (S2) threw C1 to the ground causing bruising to C1’s arm. Four (4) clients, five (5) staff and the administrator confirmed C1 is not happy at this facility and that C1 wants to leave, C1 has told some of the facility staff and other facility clients that she wants to move to another facility. One of the four clients reported that C1 does not act this way at the day program they attend. C1 only acts up when C1 gets to the facility. The administrator, three (3) staff and four (4) clients confirmed that C1 did call 911 on the date of this incident, and the police came to the facility. Police did interview C1 and staff. All interviewed confirmed, the police did not see any health or safety concern when they arrived at the facility, therefore no action was taken on that day of the incident. One of the staff stated that after the incident C1 reported to staff #4 (S4) that C1 lied about S2 hurting C1.

Based on interviews conducted, there is insufficient evidence to support the allegation that resident was injured by staff. 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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
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