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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610137
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:11:31 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
05/17/2021 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210517083344
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:
11/27/2023
UNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Gboyega AkinbolaTIME COMPLETED:
03:24 PM
ALLEGATION(S):
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Staff did not notify residents authorized representative with daily reports
INVESTIGATION FINDINGS:
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Staff did not notify residents authorized representative with daily reports
Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced subsequent complaint visit for the above allegation. LPA arrived at the facility at 1:32 pm and was greeted by staff. LPA Smith disclosed the purpose of the visit. The assistant administrator was contacted and arrived at 1:40 pm.
At 1:35 pm, LPA conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed. LPA reviewed Resident # 1 (R1) records and requested copies of documents relevant to the investigation to include but not limited to admissions agreement, Individual Program Plan (IPP) and physicians report. LPA interviewed one (01) staff and Credible witness (CW) from 1:40PM - 1:57 PM.
Allegation: Staff did not notify residents authorized representative with daily reports
It is alleged Staff did not notify residents authorized representative with daily reports for (R1). Interview with administrator revealed R1 is not conserved by individual claiming to be "authorized representative".
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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-20210517083344
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: 11/27/2023
NARRATIVE
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(Cont from 9099)

During interviews, Staff #1 (S1) revealed R1 does not have an authorized representative and is self-capable. CW revealed R1 does not have any authorized representatives in their file.
Upon review of R1’s records: the Admissions Agreement is signed by R1. R1s Quarterly Individual Service Plan (ISP) notes R1 is unconserved and any information designating an authorized representative to receive daily notes was not located in R1s record.

Based on record reviews and interviews, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted/copy of report given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2