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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603506
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:10:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240607154239
FACILITY NAME:REM CALIFORNIA, LLC - PENNSYLVANIAFACILITY NUMBER:
198603506
ADMINISTRATOR:SALAU, ADEMOLAFACILITY TYPE:
735
ADDRESS:11343 PENNSYLVANIA AVETELEPHONE:
(562) 529-2524
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY:4CENSUS: 4DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Ayo Fetuga - Caregiver/DSPTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff engaged in a verbal altercation in the presence of residents.
Staff did not provide a comfortable environment for residents.
INVESTIGATION FINDINGS:
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***This licensing report is an addition to report dated 7/23/24. This additional report is being completed in order to deliver findings on allegation “Staff did not provide a comfortable environment for residents.” Report dated 7/23/24 listed this allegation, however, findings were not delivered at that time. The substantiated findings delivered for allegation “Staff engaged in a verbal altercation in the presence of residents” on the report dated 7/23/24 will stay the same. ***

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent complaint visit on the above allegations. LPA met with Ayo Fetuga and explained the reason for the visit.

(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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 28-AS-20240607154239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA, LLC - PENNSYLVANIA
FACILITY NUMBER: 198603506
VISIT DATE: 08/15/2024
NARRATIVE
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The investigation consisted of the following:
During the initial visit on 6/13/24 LPA obtained copies of staff and resident rosters, interviews with 6 Staff and 4 Clients. LPA requested documentation from Staff #1's personnel file and family/emergency contact information for Clients 1-4, further investigation was needed.
During subsequent visit LPA delivered findings for allegation #1, and provided copies of report.
During todays visit LPA delivered findings on allegation #2.
The investigation revealed the following:
Allegations: Staff engaged in a verbal altercation in the presence of residents.
Staff did not provide a comfortable environment for residents.
It is alleged that S1 and S2 were involved in a verbal altercation while clients were in the home, making the environment uncomfortable and unsafe for the clients in care. LPA interviewed 6 staff and 6 out of the 6 staff confirmed that the altercation between S1 and S2 did occur and that this was in the presence of clients. Staff stated that altercation was over staff duties and a minor disagreement that turned into an argument in which S1 began to raise their voice and yell at S2. S1 and S2 stated that all clients were in their rooms, however, S2 stated there was a time where C2 was in the kitchen while the argument occurred, S1 sated C1 was in presence during the argument, both staff confirmed argument occurred in presence of clients. LPA interviewed 3 clients and 2 out of 3 clients stated that they overheard yelling and arguing between S1 and S2, both clients confirmed they were present during the argument, but neither could confirm what the argument was about. Both clients confirmed that S1 was the aggressor and they have overheard S1 yell or shout at other staff on multiple occasions. Both clients stated that they do not feel these arguments are about the clients at the home and do not feel unsafe because of these arguments, however, both clients feel these outbursts by S1 are unnecessary, which can potentially make an uncomfortable environment for clients in care. Interview with S6, staff stated that S1 is currently on administrative leave and pending an investigation on this incident, where a determination on whether S1 will return for work or not will be made.

Based on LPAs observations and interviews which were conducted and record review for S1, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview held and copies of the report and appeal rights were provided to Ayo Fetuga.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240607154239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - PENNSYLVANIA
FACILITY NUMBER: 198603506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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Licensee/Administrator to conduct a training covering Clients Personal Rights and proper staff etiquette while in the presence of clients, to ensure that clients are accorded dignity in their pesonal relationships with staff and other persons.
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Interviews with both staff and clients confirmed that there was a verbal altercation at the facility between S1 and S2, this altercation was in the presence of clients which did not provide clients with a comfortable environment. Therefore, based on interviews and observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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Training has been completed and training materials along with training log was provided to LPA on 8/6/2024.
***POC is cleared and a clearance letter will be emailed to Area Director Carla Lane at a later date***
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
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