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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610137
Report Date: 11/30/2021
Date Signed: 11/30/2021 11:58:11 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
11/24/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20211124140828

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:
11/30/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adeleye SotimehinTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained injuries while in care
Staff does not provide adequate transportation to resident in care
Staff did not dress resident in their correct clothing size
Staff are not providing appropriate food service to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unnanounced visit on this day in response to the above allegation.
As part of this investigation LPA interviewed the complainant telephonically on 11/29/21 and 11/30/21; interviewed the administrator, resident 1 (R1), and staff 1 (S1) on 11/30/21 at 10:00am in addition to touring the facility and inspecting its food supplies and sample menu.
Allegation #1, that "Resident sustained injuries while in care" has been unsubstantiated based on the interviews conducted and observations made. Administrator denied any recent injuries to R1, and the complainant was not able to provide any corroborating evidence. R1 denied any injuires when interviewed by LPA on 11/30/21, and LPA did not observe any injuries on R1 that match the description given by complainant.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211124140828
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: 11/30/2021
NARRATIVE
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Allegation #2, that "Staff does not provide adequate transportation to resident in care" has been unsubstantiated based on the interviews conducted. Complainant was not able to provide any additional corroborating evidence to support this allegation, and R1, S1 and the administrator all denied the allegation when interviewed on 11/30/21.

Allegation #3, that "Staff did not dress resident in their correct clothing size," has been unsubstantiated based on the observations made and interviews conducted. The complainant did not provide any corroborating evidence to support the investigation when interviewed on 11/30/21. LPA observed R1 to be wearing appropriate-sized clothing during this visit, and both R1 and the administrator denied the allegation when interviewed.

Allegation #4, that "Staff are not providing appropriate food service to resident in care," has been unsubstantiated based on the interviews conducted and observations made. Complainant did not provide any corroborating evidence to support this allegation when interviewed on 11/30/21, and R1 did not express any concerns with the food service provided when interviewed on 11/30/21. LPA confirmed that R1 does not have any special medical diet, and a review of the facility's sample menu at 11:00am and observed it to reflect a healthy variety of options. LPA also observed and documented an abundance of fresh fruit and vegetables to be available at the facility.


Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3