198320155-1-18-2024-11-AS-PBUR-CZLN55-20240118090858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320155
Report Date: 01/17/2024
Date Signed: 01/18/2024 09:09:12 AM

Document Has Been Signed on 01/18/2024 09:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	01/17/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vanessa Vazques, Kendall Edwards, Matt Robins		TIME COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management visit on Wednesday, January 17, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Program Director Vanessa Vazques and Program Supervisor Kendall Edwards. During the visit, Quality Improvement Manager Matt Robins arrived to assist with the visit. LPA Bunker explained the purpose of today's case management is to discuss the Special Incident Report Community Care Licensing received on January 02, 2024. There are currently three (3) Harbor Regional Center consumers in placement. Interviews were conducted with Staff 1-4 (S1-S4) and Clients 1-3 (C1-C3) concerning the special incident report. 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. Staff members S1-S4 confirmed that the facility staff are providing necessary care and supervision to meet the clients' needs. S2, Mr. Edwards, reported that he promptly self-reported the special incident to all relevant agencies. On January 1, 2024, the staff scheduled to work until 2:00 PM departed the facility at 1:30 PM. The relief staff, arriving at approximately 1:40 PM, found the facility's doors unattended. They 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. See continued LIC9099-C page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/17/2024

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 LIC809-C page 2

Clients 1-3 (C1-C3) expressed satisfaction with their living conditions at the facility and commended the staff's care. S1-S3 acknowledged that the client was left unattended for approximately 10-15 minutes on January 1, 2024. They stated that REM California LLC-Baltic has implemented necessary measures to prevent such incidents in the future.

Staff 1-3 (S1-S3) reported that they promptly communicated the special incident to all relevant agencies prior to today's case management 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 clients' needs. Additionally, S1-S3 mentioned that the staff are engaged in ongoing training. Staff 4 (S4), 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 emphasized the facility's compliance with Reporting Requirements. They noted that Clients 2 and 3 (C2-C3) were not present during the incident. An Unusual Incident Report was submitted 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.

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.

There were no deficiencies cited

Exit interview conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2