<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320155
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:17:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2024 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20240110091921
FACILITY NAME:REM CALIFORNIA LLC - BALTICFACILITY NUMBER:
198320155
ADMINISTRATOR:WHITLEY JOHNFACILITY TYPE:
735
ADDRESS:2800 BALTIC AVETELEPHONE:
(562) 424-9555
CITY:LONG BEACHSTATE: ZIP CODE:
90810
CAPACITY:3CENSUS: 3DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kendall EdwardTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision of a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Complaint visit on Thursday, January 18, 2024. LPA Bunker met with Program Supervisor Kendall Edwards. During the visit, Program Director Vanessa Vazquez arrived to assist with the visit. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: Interviews were conducted with staff members 1-5 (S1-S5) and Clients 1-3 (C1-C3) concerning the above complaint allegation. LPA Bunker posed questions pertinent to the incident's nature. During the inspection, S3, Mr. Robins, and LPA Bunker toured the entire facility, including buildings and grounds, to identify any signs of neglect, abuse, or other immediate health and safety threats. No evidence of neglect or abuse was observed during today's visit. LPA Bunker requested copies of various documents, including the special incident report, personnel report, client roster, REM California LLC-Baltic Investigation report, and Harbor Regional Center report.
See continued LIC9099-C page 2

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 5
Control Number 11-AS-20240110091921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA LLC - BALTIC
FACILITY NUMBER: 198320155
VISIT DATE: 01/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued LIC9099-C page 2

Allegation: Neglect/Lack of Supervision of a client.
Staff members S1-S5 confirmed that the facility staff is providing necessary care and supervision to meet the client's needs. S1 reported that he promptly self-reported the special incident to all relevant agencies, on January 2, 2024, S1 stated the staff on duty was scheduled to work until 2:00 P.M., staff departed the facility at 1:30 P.M. The relief staff, arriving at approximately 1:40 P.M., and found the facility's door unlocked. Staff entered through an unlocked side gate and back door, discovering the client alone in his bedroom watching TV. The staff ensured the client's safety and well-being. S1-S4 agreed client was left unsupervised for approximately 10-15 minutes between shift changes.

Investigation revealed the following: During interviews, with staff members S1-S3. S1 stated that on Monday morning, 01/01/2024, at 8:16 A.M., staff requested verbal approval to leave at 1:30 P.M. S1 stated on Monday, 01/01/2024, at 1:03 P.M., staff texted "please remember I requested to leave at 1:30 P.M." S1 stated he did not respond to the text message. S1 stated staff texted again at 1:47 P.M., and stated he locked the front door and left through the backyard door. S1 stated he replied back at 2:16 P.M., "That's not okay and the next shift staff came in at 1:40 P.M.," S1-S4 affirmed that the staff is well-trained and competent, equipped to provide the necessary services to meet the client's needs. S1-S3 mentioned that the staff are engaged in ongoing training. Staff 5 (S5), serving as a substitute, stated she was not informed about the incident. Clients 1-3 (C1-C3) confirmed that they are consistently provided with necessary care and supervision, ensuring they are never left at home unattended. S1-S3 stated the staff involved were placed on unpaid administrative leave, pending the investigation's outcome. S1-S3 further stated that the staff member was terminated due to leaving a client unsupervised for approximately 15 minutes during a shift change. S1-S4 acknowledged that the client was left unattended for approximately 15 minutes on January 1, 2024. S1-S3 stated that REM California LLC-Baltic has implemented necessary measures to prevent such incidents in the future.

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are being cited on the attached LIC9099-D.
Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-A, LIC9099-Cs, and LIC9099-D were provided to Program Supervisor Kendall Edwards.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2024 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20240110091921

FACILITY NAME:REM CALIFORNIA LLC - BALTICFACILITY NUMBER:
198320155
ADMINISTRATOR:WHITLEY JOHNFACILITY TYPE:
735
ADDRESS:2800 BALTIC AVETELEPHONE:
(562) 424-9555
CITY:LONG BEACHSTATE: ZIP CODE:
90810
CAPACITY:3CENSUS: 3DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kendall EdwardTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow Reporting Requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Complaint visit on Thursday, January 18, 2024. LPA Bunker met with Program Supervisor Kendall Edwards. During the visit, Program Director Vanessa Vazquez arrived to assist with the visit. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: Interviews with staff members 1-5 (S1-S5) and clients 1-3 (C1-C3). Alleged allegation: Staff did not follow reporting requirements. Staff 1-3 (S1-S3) reported that they promptly communicated the special incident to all relevant agencies prior to today's complaint visit, in accordance with proper protocols. They affirmed that the staff is well-trained and competent, equipped to provide the necessary services to meet the client's needs. Additionally, S1-S4 mentioned that the staff are engaged in ongoing training. Clients 1-3 (C1-C3) confirmed that they are consistently provided with necessary care and supervision, and clients' families, next of kin, conservatories, and responsible parties are made aware of unusual incidents.
See continued LIC9099-C page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20240110091921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA LLC - BALTIC
FACILITY NUMBER: 198320155
VISIT DATE: 01/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued LIC9099-C page 2

Investigation revealed the following: During interviews, staff members S1-S3 confirmed that all pertinent information regarding this matter was promptly reported to Community Care Licensing (CCL) and all other relevant agencies, ensuring compliance and transparency in their operations. S1-S3 emphasized the facility's compliance with Reporting Requirements. S1-S3 stated an Unusual Incident Report was submitted and faxed to the Monterey Park office at (323) 980-4912 to the licensing agency on the next working day, 01/02/2024, within standard business hours. S1-S3 disclosed that the staff self-reported the special incident to all appropriate agencies within a 24-hour period, adhering to Title 22 Regulations. S1 stated on 01/10/2024, he received a telephone from CCL representative Danny, who stated he did not see the Special Incident Report dated 01/02/2024, and he provided S1 with the correct fax number for the El Segundo office (424) 544-1016. S1 stated Danny said someone would be coming out to the facility. S1-S3 denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the facility staff.

There were no deficiencies cited. Exit interview conducted
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240110091921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA LLC - BALTIC
FACILITY NUMBER: 198320155
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2024
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 (a) Responsibility for Providing Care and Supervision:
The licensee shall provide care and supervision as necessary to meet the client's needs.
On January 1, 2024, client was left unattended for approximately 10-15. minutes unsupervised.
1
2
3
4
5
6
7
The licensee agrees to submit a written plan that staff will be trained on Responsibility for Providing Care and Supervision to ensure the facility has sufficient and competent staff available to provide the services needed to meet client needs.
By the POC due date of 02/17/2024
8
9
10
11
12
13
14
The violation poses an immediate health and safety risk to residents in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5