198320155-10-2-2024-11-AS-UCOL-DA52BV-20241016171545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320155
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:17:50 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20231003103454

FACILITY NAME:	REM CALIFORNIA LLC - BALTIC		FACILITY NUMBER:	198320155
ADMINISTRATOR:	WHITLEY JOHN		FACILITY TYPE:	735
ADDRESS:	2800 BALTIC AVE		TELEPHONE:	(562) 424-9555
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90810
CAPACITY:	3	CENSUS: 3	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	ADMINISTRATOR STACEY CHEAT		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained injury due to staff not preventing resident from being physical abuse by another resident

INVESTIGATION FINDINGS:

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On 10/02/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to REM California LLC -Baltic facility and was greeted by Administrator Stacey Cheat (S3). LPA Calderon explained the purpose of this visit is to deliver and amendment of the complaint investigation report for the complaint control number 11-AS-202310031103454. This report supersedes the report dated 10/13/2023, finding have changed from Unsubstantiated to Substantiated.
Finding pertaining to the above-mentioned allegations
The investigation consisted of the following: On 10/13/2023 LPA Calderon conducted a tour of the facility. LPA Calderon interviewed staff S1-S3 and interview clients C1-C3. LPA Calderon obtained and reviewed the following records: Physician Report dated 09/22/2023, Individual Service Plan (ISP) dated 11/05/2020 and 08/04/2023, Incident reports dated 10/02/2023, Behavioral consulting board analysis (BCBA) dated 10/09/2023 for C1-C2. Conflict/redirection training for staff dated 10/04/2023, Weekly reinforcer behavior plan for C2 training dated 09/26/2022, Safety Net training dated 09/28/2023.
The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 3

Control Number 11-AS-20231003103454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REM CALIFORNIA LLC - BALTIC	FACILITY NUMBER: 198320155
	VISIT DATE: 10/02/2024

NARRATIVE

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Regarding Allegation: “Resident sustained injury due to staff not preventing resident from being physically abused by another resident”. It is being alleged that staff S1 did not prevent and altercation between 2 clients. Record reviews indicate the following: Individual Service Plan (ISP) dated 08/04/2023 for C2 indicates that C2 gets frustrated when C2 can’t express C2 clearly or when staff don’t understand what C2 is trying to say. C2 is unhappy and will have emotional outbursts if C2 is unable to gain access to actives, food, reminder from staff about personal space and when C2 has spent all C2 money. C2 will use profanity, threats to leave the home, punching walls, playing loud music, and pacing back and forth. Staff will support C2 by directing C2 to C2 calendar as a reminder of when those activities will happen. Weekly reinforcer behavior training plan for C2 dated 09/26/2022, training was provided to observe C2 for behavioral changes. Reviewed the employee safety intervention steps training dated 10/04/2023, behavioral coaching, when to intervene and not to intervene during escalation from an individual, use of correct verbiage. Memorial Care after visit summary date 10/02/2023 indicate that C1 was taken to the emergency department for a bruising and a black eye. Interviews indicate the following: 3 out of 3 clients indicate that, C2 had punched C1 in the eye for unknown reasons. C2 indicates that S2 was not paying attention to what C2 had to say and C2 got mad.C2 indicates that C1 was making faces at C2 and C2 got mad and punched C1 in the face. C3 indicates that C3 did not know what happened between C1 and C2 and did not witness the attack, but that C3 has not had any issues with C2. S3 indicates that C2 attacked C1 and punched C1 left face. S3 indicates that C2 was taken to the hospital for a 5250 hold and was in the hospital for 14 days. S1 indicates that on 10/02/2023 C2 finished eating his food, was pacing back and forth, has attacked C1 in the past and there was nothing S1 could have done to prevent C2 from attacking C1. S2 indicates that C2 was aggressive with staff and other clients. S2 indicates that S2 was making breakfast for clients and S2 heard a thump but did not see anything. S2 indicates that C2 had taken a bottle from the kitchen area. S2 indicates that C2 asked for staff to go to his room. S2 indicates that S2 said no to C2 and gave other options to C2 and then C2 punched C1. S2 indicates that C1 was not injured and that S2 had never received any training in handling or redirecting clients’ actions.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of “Resident sustained injury due to staff not preventing resident from being abused by another resident” is found to be SUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report were provided to the Administrator Stacey Cheat. (S3)

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231003103454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REM CALIFORNIA LLC - BALTIC	FACILITY NUMBER: 198320155
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/31/2024 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072 Personal Rights(a)Except for children’s residential facilities, each client shall have personal rights which include..(3) To be free from corporal or unusual punishment, infliction of pain.. This requirement was not met as evidenced by	1 2 3 4 5 6 7	Administrator will submit a plan on how the facility staff will be trained on how to redirect clients’ behaviors.
	8 9 10 11 12 13 14	Based on (interview) (record review)], the licensee did not comply with the section cited above. The facility staff failed to prevent C2 from attacking C1. This poses/posed health, safety, or personal rights risk to persons 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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