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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320234
Report Date: 05/06/2024
Date Signed: 05/06/2024 11:13:44 AM

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
02/14/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240214090258
FACILITY NAME:REM CALIFORNIA, LLC - MARCELLUSFACILITY NUMBER:
198320234
ADMINISTRATOR:PAGE, LATORIFACILITY TYPE:
735
ADDRESS:1024 E. MARCELLUS ST.TELEPHONE:
(562) 866-9634
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:3CENSUS: 2DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Glendy Franco, Program SupervisorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Staff did not report incident to appropriate parties
INVESTIGATION FINDINGS:
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5
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13
On 5/6/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Program Supervisor, Glendy Franco, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:

On 2/22/24, LPA Felisa Shirley spoke to facility Administrator, Ife James on the phone and Quality Assurance Representative Richard Briseno came out immediately to assist. LPA requested and reviewed the following: LIC 500, Client Roster, Admissions Agreement, Training Credentials

The investigation revealed the following:
Cont'd 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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-20240214090258
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 - MARCELLUS
FACILITY NUMBER: 198320234
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Staff did not report incident to appropriate parties


It is being reported that staff did not report an incident in which a client needed the heimlich maneuver performed on them. During file review, LPA observed the physician’s report stating that resident is able to feed themselves, but the weekly PRN Comprehensive Nursing Assessment stated that resident’s diet is mechanical soft and needs verbal prompts to slow down between bites. Resident was eating an item that is determined not to be mechanical soft which resulted on resident choking on an item and the Heimlich maneuver being performed. During file review and interviews LPA learned that an incident report was not filed and incident not being reported to CCLD. On 2/22/24, LPA conducted interviews with both staff and residents. LPA interviewed staff, staff 1 – staff 7 (S-1 – S-7). LPA asked if staff, “Are all incidents reported to the appropriate parties?” Of those interviewed 6 out of 7 stated yes. S-7 was not available for interview. LPA interviewed residents 1 – resident 2 (R-1 – R-2). LPA asked residents, has there been an incident with you that happened that needed to be reported to management. Of those interviewed, 1 out of 2 answered, no. According to the information gathered and the acknowledgment declaration from staff, there is sufficient evidence to support the allegation mentioned above. Based on information gathered, the department did find sufficient evidence to support allegations "Staff did not report incident to appropriate parties.” Therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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, 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
02/14/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240214090258

FACILITY NAME:REM CALIFORNIA, LLC - MARCELLUSFACILITY NUMBER:
198320234
ADMINISTRATOR:PAGE, LATORIFACILITY TYPE:
735
ADDRESS:1024 E. MARCELLUS ST.TELEPHONE:
(562) 866-9634
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:3CENSUS: 2DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Glendy Franco, Program SupervisorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee do not ensure that staff has required training
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/6/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Program Supervisor, Glendy Franco, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:

On 2/22/24, LPA Felisa Shirley spoke to facility Administrator, Ife James on the phone and Quality Assurance Representative Richard Briseno came out immediately to assist. LPA requested and reviewed the following: LIC 500, Client Roster, Admissions Agreement, Training Credentials

The investigation revealed the following:
Cont'd 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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-20240214090258
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 - MARCELLUS
FACILITY NUMBER: 198320234
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Licensee do not ensure that staff has required training

It is being reported that the staff did not have the proper training and does not have experience working with developmentally disabled residents. During file review, LPA Shirley observed the training credentials of staff on duty on the day in question in which there was an incident that a resident was alleged to be choking on a foreign object. LPA interviewed staff, staff 5 – staff 6 (S-5 and S-6). LPA asked if staff, “Do you have your DSP 1 and 2? Which trainings have you had.” Of those interviewed 2 out of 2 presented copies of their DSP credentials, CPR and CPI cards. LPA interviewed residents 1 – resident 2 (R-1 – R-2). LPA asked residents, do you feel that the staff here are properly trained. Of those interviewed, 1 out of 2 answered, yes. According to the information gathered and the acknowledgment declaration from staff, there is insufficient evidence to support the allegation mentioned above. Based on information gathered, the department did not find sufficient evidence to support allegations Licensee do not ensure that staff has required training.

An exit interview was conducted and a copy of the LIC 9099, and appeal rights forms were provided to Program Supervisor, Glendy Franco.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240214090258
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 - MARCELLUS
FACILITY NUMBER: 198320234
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2024
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

This requirement is not met as evidenced by:

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Licensee/Administrator will review regulation 80061 in its entirety and provide a written statement saying its has been read and understood to CCLD via fax or email by POC due date.
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Based on interview, and record review on 2/1/24, the licensee did not report an incident that involved R1 which posed a a potential health risk to persons in care.
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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: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5