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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610133
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:25:06 PM

Unsubstantiated


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:
08/28/2024
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Gboyega Akinbola- AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Facility did not adhere to residents' Admission Agreement.
INVESTIGATION FINDINGS:
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9
10
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13
Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted a subsequent complaint visit to the facility to investigate the above allegations. LPA met with the Area Director, Kenda Comstock, and advised them regarding the visit. At 1PM LPA conducted a physical plant tour to ensure the health and safety of the residents in care.

Allegation: Facility did not adhere to residents' Admission Agreement.

In regard to the allegation, it was reported by another agency that the licensee did not adhere to residents' Admission Agreement. It was also reported that dietician consultant services have not been provided to either resident since January 12, 2024. Moreover, the facility administrator was unable to verify how many hours of Registered Nurse consult services were provided per resident as required from the period of January through August 2024.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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 2
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: 08/28/2024
NARRATIVE
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As a result of this, the facility was given a Corrective Action Plan (CAP) by this agency.

Community Care Licensing Division (CCLD) works in conjunction with this agency to ensure facility compliance. Therefore, based on information and CAP obtained, the above allegation is unsubstantiated because allegation was not indicated in admission agreement, but was indicated in their facility program in page 28. Citation will be given as case management.

Exit interview conducted. Administrator advised and a copy of this repor
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2