197610133-3-28-2025-31-AS-NMAN-DFJVLP-20250408163215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610133
Report Date: 03/28/2025
Date Signed: 03/28/2025 03:43:38 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.ASC, 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
05/17/2024 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20240517111755

FACILITY NAME:	REM CALIFORNIA LLC - NAPA		FACILITY NUMBER:	197610133
ADMINISTRATOR:	IBRAHIM, MOSHOOD		FACILITY TYPE:	735
ADDRESS:	16214 NAPA ST		TELEPHONE:	(818) 892-2800
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	4	CENSUS: 4	DATE:	03/28/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Gboyega Akinbola		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff caused injury to client in care

INVESTIGATION FINDINGS:

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At approximately 9:00 a.m. on 03/28/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit.

To investigate the allegation above, LPA Smith conducted an initial visit at approximately 10:35 a.m. on 05/24/24 and interviewed the administrator and staff, obtained pertinent records, and toured the facility. Today, LPA Reed toured the facility at 9:30 a.m., interviewed staff and clients between 10:00 a.m. and 3:00 p.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, care plan, body scan notes, and staff and client rosters at 1:00 p.m.

Regarding the allegation "Staff caused injury to client in care" it was alleged that unexplained injuries were found on the left eyelid and left shoulder of Client #1 (C1) on 05/15/2024. It was noted that C1 had a history of being aggressive and making grandiose and delusional statements.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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-20240517111755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - NAPA	FACILITY NUMBER: 197610133
	VISIT DATE: 03/28/2025

NARRATIVE

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Record review of C1’s service plan revealed they have a history of verbal and physical aggression, property destruction, and self-injury. Review of after-shift notes from 05/10/24 revealed C1 engaged in self-injurious behavior on the evening of 05/09/24 and told staff “I fell”. Staff noted redness around C1’s eye, cheek, and neck. C1 declined first aid. An incident report submitted by the facility confirmed the details of the injuries from 05/09/24. The facility also submitted an incident report on 05/11/24 detailing that C1 fell out of their bed. Staff observed a bruise on C1’s torso. Body scan notes revealed that staff observed scratches on C1’s left eye and neck on 05/09/24, a black eye on C1’s left eye on 05/10/24, and bruising on C1’s upper left torso on 05/11/24. C1’s eye and torso bruising persisted until 05/17/24.

Interview with Staff #1 (S1) at 10:00 a.m. today revealed C1 has been physically aggressive, self-injurious, and has engaged in property destruction. Staff have frequently observed injuries on C1 from their behaviors and after returning from their day program. S1 noted C1 usually has marks and bruises on their arms and torso. Interview with all staff and the administrator confirmed that staff complete body scans every shift and record their findings. Interview with C1 at 3:00 p.m. today revealed they did not remember the cause of their injuries, but C1 noted staff did not cause the injuries to them. LPA did not observe any injuries on C1’s face or arms today.

Based on observations, interviews, and record review, there is no evidence indicating that staff caused C1’s injuries. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety concerns were observed during today’s visit.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC9099 (FAS) - (06/04)

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