197610133-5-6-2024-31-AS-NMAN-D5SPUV-20240531113809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610133
Report Date: 05/06/2024
Date Signed: 05/06/2024 11:43:58 AM

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
04/20/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230420112938

FACILITY NAME:	REM CALIFORNIA LLC - NAPA		FACILITY NUMBER:	197610133
ADMINISTRATOR:	IBRAHIM, MOSHOOD		FACILITY TYPE:	735
ADDRESS:	16214 NAPA ST		TELEPHONE:	(909) 483-2505
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	4	CENSUS: 4	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	11:07 AM
MET WITH:	Hawa Mivindu, DSP		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff punched client resulting in bruising

INVESTIGATION FINDINGS:

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***This is an amended copy of the report previously issued on 02/17/2024. After review of this complaint, it was determined corrections to document placement was warranted. No changes to orginal verbaige were made and the complaint findings remain the same .****

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 2:30 pm to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit.

A 10-day visit was conducted by Licensing Program Analyst (LPA) Melissa Ruiz on 04/21/2023, at which time LPA Ruiz conducted a physical plant tour at around 10:15 am and conducted an interview with staff at 10:45 am.

Staff punched client resulting in bruising
(Cont to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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-20230420112938

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 - NAPA	FACILITY NUMBER: 197610133
	VISIT DATE: 05/06/2024

NARRATIVE

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(Cont from 9099)

It was alleged that staff punch Resident #1 (R1) resulting in bruising. To investigate the allegation: On 07/18/2023 LPA Tihesha Smith made a visit, at which time LPA Smith conducted a physical plant tour at around 10:30 am and conducted an interview with staff and requested documents relevant to the investigation from 10:45 am- 2:00 pm. S1 and R1 were not present at the facility.

Facility records which include Service plan and Physicians report revealed that R1 has a history of maladaptive behaviors which include but not limited to aggression, punching, kicking, throwing objects, cursing and tantrums. Interviews with five (5) out of five (5) staff reveal have never punched or hit any resident in care. Interview with S2 revealed R1 punched S1 then S1 used Supine technique on R1 but did not punch R1 in the eye. After the technique, no visible injuries were observed on R1. Interview with R1 on 02/17/2024 revealed have not been hit or punched by staff.

Overall, the investigation revealed that although R1's eye was bruised S1 did not punch R1. R1 punched S1 and as a result of position change during Supine procedure to restrain R1, R1's eye was injured. Therefore, based on the information revealed from interviews and records review, the above stated allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted, copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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