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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610133
Report Date: 08/12/2024
Date Signed: 08/12/2024 02:18:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
08/02/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20240802122246
FACILITY NAME:REM CALIFORNIA LLC - NAPAFACILITY NUMBER:
197610133
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:16214 NAPA STTELEPHONE:
(818) 892-2800
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 3DATE:
08/12/2024
UNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Adeleye Sotimehin- DesigneeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not properly manage hazardous waste.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda conducted an unannounced complaint visit to this facility to investigate the above allegations. LPA met with the facility staff Hawa Mivindu, who granted access to the facility. Facility designee Adeleye Sotimehin arrived shortly at 11:28 AM and LPA explained the reason for the visit—an entrance interview was conducted.

At approximately 10:48 AM, with the assistance of the staff LPA conducted a physical plant tour, to ensure the health and safety of the residents are protected and the physical plant is in compliance with Title 22 Regulations. During the investigation, interviews and record reviews were made. At 11:40 AM, LPA requested the resident and staff roster. At 11:50 AM, LPA requested copies of pertinent information which include, but are not limited to an admission agreement, CSMDR, MAR, Physician’s Report, LIC 500, LIC 9020, and any document relevant to the investigation.

Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
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 4
Control Number 31-AS-20240802122246
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - NAPA
FACILITY NUMBER: 197610133
VISIT DATE: 08/12/2024
NARRATIVE
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Between 11:18 am and 12 NN, LPA interviewed the Administrator and three (3) staff members. From 2PM to 2:10PM LPA interviewed two (2) out of three (3) clients.
Allegation: Staff did not properly manage hazardous waste.
The incident occurred on 7.18.2024 in the facility's kitchen, when a credible witness observed that expired medication was kept in a locked cabinet and accessible to clients in care. Also, it was alleged that a syringe was found in the sharp box that was unlocked and one (1) syringe was found inside the sharp waste disposal box. To investigate this allegation, LPA interviewed the designee, three (3) staff members, and two (2) out of three (3) clients. During today’s visit, LPA confirmed and identified that the facility did not properly dispose of expired medication, and it was kept unlocked and accessible to clients in care. Staff confirmed that resident #1 (R1) syringe was stuck in the sharp waste disposal was kept unlocked and was not disposed of properly. In addition, the staff admitted the error and findings. This is an immediate health and safety risk to clients in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

An exit interview was conducted, and a hard copy of this report was given.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240802122246
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - NAPA
FACILITY NUMBER: 197610133
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
HSC
80075(k)(1)
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80075 Health Related Services: (k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible..
This requirement is not met as evidence by:
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Administartor will email training certificate done by staff to RO by 8.16.2024.
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Based on interviews & record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to keep residents expired medication locked inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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Type A
08/16/2024
Section Cited
CCR
80087(g)(1)
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(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Administartor will email training certificate done by staff to RO by 8.16.2024.
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Based on interviews & record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to keep residents waste disposal box for syringe was unlocked and was accessible to clients, which poses 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4