198320232-1-6-2024-11-AS-MVAO-CZF293-20240112161116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320232
Report Date: 01/05/2024
Date Signed: 01/06/2024 01:13:24 PM

Unsubstantiated

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
12/01/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231201152515

FACILITY NAME:	REM CALIFORNIA, LLC - E 213TH		FACILITY NUMBER:	198320232
ADMINISTRATOR:	PAGE, LATORI		FACILITY TYPE:	735
ADDRESS:	1356 E 213TH ST		TELEPHONE:	(562) 912-7710
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	4	CENSUS: 3	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	08:04 AM
MET WITH:	Latori Page		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff member caused an injury to resident while in care.

INVESTIGATION FINDINGS:

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On 12/05/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. LPA was greeted by care staff Mary Ronn. Ronn contaced Executive Program Director Latori Page who spoke with LPA by telephone and provided the purpose of this investigation.

The investigation consisted of the following: Interveiwes with staff #1 - #3, clients #1 - #3, and witness #1. A review of roster for clients and staff., service records for client #1 (C1) and staff #1 (S1), Carson Sheriff Station police report, and other pertinent documents associated with this complaint. A physical tour of the facilty was conducted.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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 4

Control Number 11-AS-20231201152515

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 - E 213TH	FACILITY NUMBER: 198320232
	VISIT DATE: 01/05/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff member caused an injury to resident while in care.
On 12/01/23, The Department received a complaint alleging client #1 (C1) was injured while in care by staff at this facility. The complainant reported (C1) did not feel comfortable at this facility. (C1) complained of pain in the arm and staff #1(S1) grabbed (C1) by the arm which caused bruising on the arm that appeared to be discolored. The complainant reported the incident occurred the week of week of 11/19/23 through 11/25/23. The complainant reported there were no open wounds and the bruising did not appear fresh so no medical attention was provided. The complainant did not have further details nor the alleged actual date of the offense.

On 12/01/23, the Department investigated a visit to this facility between 09:30 pm - 01:09 pm. Documents for (C1's) service records along with staff #1 (S1) personnel records and other pertinent documents associated with this complaint were obtained during the visit. The Department interviewed (2) out of (2) staff #2-#3 both staff reported this information was new information and that (C1) claimed to have been pushed by staff #1 (S1) at the home while medications were being passed out in the evening. (S2) is unaware of the date and time this incident occurred. (S2) immediately reported the incident to Harbor Regional Center (HRC), Community Care Licensing (CCL), and Carson Sheriff Station. (S2) was advised to remove (S1) from the work schedule until the investigation is completed. (S2-S3) denied (C1) or (S1) ever having any conflict or uncomfortable behaviors with one another. (S2) claimed that staff conducts routine daily body checks on all clients. Medical attention was offer to (C1), but refused the service. During the visit, the Department observed (C1) who was experiencing uneasiness or apprehension was not interviewed during the investigation visit.

On 01/05/24 from 10:20 am – 10:51 am, the Department interviewed client #1 (C1) was interviewed through assistance from Focus Language International, Inc. (Focus) provided the Department with telephone-based oral interpretation service. (C1) stated to have lived at the home for five weeks. (C1) claimed to like the home. (C1) claimed to feel safe at home. (C1) claimed to get along with everyone at the home. (C1) claimed to like all the staff and is treated well. (C1) did not have concerns for (C1’s) safety while being cared for at this home. When asked if one staff member did not treat (C1) well, (C1) mentioned (S1). (C1) was described as not being treated well by (S1) and was pushed down on the floor during a time when medications were distributed.
(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231201152515

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 - E 213TH	FACILITY NUMBER: 198320232
	VISIT DATE: 01/05/2024

NARRATIVE

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On 12/01/23 – 01/05/24, service records for (C1) were reviewed. Records revealed that (C1) has lived at the facility since 10/15/20 and not five weeks as claimed by (C1). (C1) is diagnosed with a mental disorder and a loss of intellectual function according to (C1’s) Physician’s Report for Residential Care Facilities LIC 602A (dated: 09/08/23). The Department did not observe any bodily injuries on (C1) 12/05/23 and 01/05/24.

On 12/01/23 – 01/05/24, the Department reached out to family representatives of (C1) and interviews were not available.

Based on the information gathered, there is not enough evidence to corroborate the allegation.

Based on the information provider, an inspection of the facility, observation, interviews, and analysis of service records, (C1's) conflicting statements, no medical assessment for injuries, the Department found no evidence to support the allegation mentioned above.

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, as a result, the allegation is Unsubstantiated.

No deficiencies were identified during this visit.

An exit interview was conducted with Latori Page, and a copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20231201152515

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 - E 213TH	FACILITY NUMBER: 198320232
	VISIT DATE: 01/05/2024

NARRATIVE

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(C1) claimed that it was only (S1) who was present during that time and no other roommates or other staff were present when this incident occurred. (C1) could not recall the date and time when (S1) had pushed (C1) down to the ground and was eventually grabbed by (S1) by the arm. (C1) claimed to have suffered scratches on the elbow and right knee. During the interview, (C1) continued to make inconsistent statements regarding the allegation and continued to deviate from the subject matter.

On 01/05/24 at 10:51 am – 11:40 am, the Department interviewed (2) out of (2) clients #2-#3 (C2-C3) who were complimentary of staff. (C2-C3) reported enjoyed living at this facility and was happy and safe at the facility. (C2-C3) claimed to receive medications with other roommates present evening intakes and there has never been a time when medications were taken alone with only a staff member. (C2-C3) denied ever being physically abused at any time while in care at this facility.

On 01/05/24 at 11:50 am – 12:01 pm, the Department interviewed staff # (S1). (S1) claimed to be aware of the accusation involving (C1) and denied this incident ever happened. (S1) stated no such abuse happened. (S1) stated there was no altercation involving (C1). (S1) described that medications are passed out regularly along with other clients at the home. (S1) stated that one of the clients would have been a witness to this alleged incident. (S1) stated to be uncertain why anyone would make false statements. (S1) claimed to have never had any conflict or uncomfortable behaviors with (S1) claimed to have completed all the mandatory required training on suspected abuse or neglect and is knowledgeable of the Zero Tolerance for Abuse Policy.

On 12/01/23 Carson Sheriff Station (CSS) and on 12/05/23 Harbor Regional Center (HRC) conducted their investigation and determined (C1) provided contradictory statements of what had happened on the day of the alleged incident. Investigation revealed based on observation and (C1’s) statements, (C1) is healthy and well-taken care and no evidence of elder/dependent adult abuse.

On 12/01/23, the facility conducted a Quarterly Health and Safety Assessment with a Licensed Vocational Nurse with (C1). (C1) claimed to feel safe at home and the overall service received was beneficial. (C1) claimed to like the people who live at home and like the people who are working at home.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

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