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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610137
Report Date: 08/11/2022
Date Signed: 08/11/2022 04:22:42 PM

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
04/23/2021 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20210423093327
FACILITY NAME:REM CALIFORNIA LLC - OSBORNEFACILITY NUMBER:
197610137
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:15952 OSBORNE STTELEPHONE:
(818) 893-1234
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
08/11/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Adeleye Sotimehin TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not seek medical care for resident
Facility did not inform responsible party of resident's change in condition
Staff verbally threatened resident
INVESTIGATION FINDINGS:
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On 08/11/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct a subsequent complaint visit. Upon arrival LPA met with administrator Adeleye Sotimehin and the purpose of the visit was explained. Initial visit was conducted on 04/30/21.

Allegation# 1 Facility did not seek medical care for resident
It is alleged that C1 tripped over a shoe on 04/13/21 and the facility did not provide medical attention. LPA did not find any incident report related to the alleged incident in the departments database. LPA also reviewed all incident reports archived at the facility and did not find any documentation regarding an incident on that day. Interviews with Administrator and staff determined the alleged incident never occurred. Four (4) out of four (4) staff stated they do not recall the alleged incident therefore, no medical attention was necessary. Based on the information obtained this allegation is deemed Unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
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-20210423093327
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 - OSBORNE
FACILITY NUMBER: 197610137
VISIT DATE: 08/11/2022
NARRATIVE
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Allegation #2 Facility did not inform responsible party of resident's change in condition.

It is alleged that facility did not inform C1 responsible party of clients change of condition. According to the interview with administrator, C1 has not had any change of condition, nor any serious injuries. C1 has been only been to the Emergency Department once this year and according to medical documents there were no injuries, nor change of condition. LPA obtained C1’s Individualized Program Plan no change of condition was noted. Based on the information received, this allegation is deemed Unsubstantiated.

Allegation #3 Staff verbally threatened resident

It is alleged that staff verbally threatened a client. To investigate this allegation LPA conducted interviews with clients and staff member. According to four (4) out of four(4) staff members, no staff has threatened or witness another staff threatening clients. Four (4) out of four (4) clients stated they have not been threatened by any staff. Based on the information received, this allegation is deemed Unsubstantiated.

No deficiencies issued. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2