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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603511
Report Date: 08/22/2025
Date Signed: 08/22/2025 12:20:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
12/06/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241206090302
FACILITY NAME:REM CALIFORNIA, LLC - PARK STREETFACILITY NUMBER:
198603511
ADMINISTRATOR:MURRAY, MARSHAFACILITY TYPE:
735
ADDRESS:9559 PARK STREETTELEPHONE:
(562) 263-6036
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:3CENSUS: 1DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Marsha Murray, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not provide the client medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegation listed above. LPA met with the Administrator, Marsha Murray, and explained the purpose of the visit.

The investigation consisted of the following:
On 12/12/24, LPA Chan toured the facility and collected documents for Client #1. Interviews were held with the administrator and 3 Staff. On 4/11/25, LPA Chan obtained additional documents on Client #1 and interviewed staff.

The investigation revealed the following:
Allegation – Staff did not provide client medical attention in a timely manner. It is alleged that Client #1 (C1) had high blood sugar (BS) level readings, and staff did not notify the medical doctors or transport C1 to the hospital. As a result, C1 developed diabetic ketoacidosis (DKA).
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
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 28-AS-20241206090302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA, LLC - PARK STREET
FACILITY NUMBER: 198603511
VISIT DATE: 08/22/2025
NARRATIVE
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During the investigation, LPA reviewed medical records for C1 and interviewed facility staff. Based on the medical records, C1’s blood sugar level is tested about 5 times a day, and the staff refer to a sliding scale to provide the number of insulin units. C1 also has a physician’s order dated 9/24/2024, which stated “call MD if BS remained above 250 consistently.”

LPA gathered and reviewed C1’s BS level readings and medication logs for September 2024 – November 2024, and the facility shift notes. C1’s records revealed that the C1’s BS levels remained above 250 after insulin was given and/or one to two hours after presumed meal consumption for several occasions. For the period, 09/27/24 through 09/30/24, C1’s BS levels remained mostly above 200 mg/dL, on five occasions the readings were above 250 mg/dL. On 10/29/24, from 11:48am to 7:02pm, there were three consecutive BS readings above 250 mg/dL. On 11/05/24, the BS levels remained above 200 mg/dL for at least five hours in the morning even after insulin was administered. Due to the frequent high BS levels, staff did not contact C1’s physician as directed in C1’s physician order dated 9/24/2024, therefore staff did not obtain timely medical treatment for C1’s restricted health condition.

Five (5) out of five staff interviewed did not have a clear understanding and could not explain what the C1’s physician meant by the term “consistently” as listed on C1’s written order. Staff stated they were not persistent in contacting C1's physician when C1's BS levels went above 250 mg/dL. Staff also acknowledged that there was no staff training provided to staff regarding C1’s restricted health condition.

Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D. There is no civil penalty assessed today. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).



An exit interview was conducted. The Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20241206090302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REM CALIFORNIA, LLC - PARK STREET
FACILITY NUMBER: 198603511
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2025
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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The licensee shall ensure that all staff providing care and supervision shall receive a clear understanding and follow the physician's order. A plan shall be develop to ensure staff follow physician's orders and administering insulin and all medications accurately. Plan is due to LPA by 8/23/25.
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Based on record review and interviews, staff did not follow the physician's order to contact the doctor when Client #1's blood sugar went over 250 mg/dL consistently which poses an immediate health and safety risk to clients 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
12/06/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241206090302

FACILITY NAME:REM CALIFORNIA, LLC - PARK STREETFACILITY NUMBER:
198603511
ADMINISTRATOR:MURRAY, MARSHAFACILITY TYPE:
735
ADDRESS:9559 PARK STREETTELEPHONE:
(562) 263-6036
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY:3CENSUS: 1DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Marsha Murray, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Client sustained infection(s) while in the care of staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegation listed above. LPA met with Administrator, Marsha Murray, and explained the purpose of the visit.

The investigation consisted of the following:
On 12/12/24, LPA Chan toured the facility and collected documents for Client #1. Interviews were held with the administrator and 3 Staff. On 4/11/25, LPA Chan obtained additional documents on Client #1 and interviewed staff.

The investigation revealed the following:
Allegation – Client sustained infection(s) while in the care of staff. It is alleged that client #1 (C1) sustained a kidney infection due to high blood sugar levels. LPA obtained and reviewed C1’s medical records and facility notes.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20241206090302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA, LLC - PARK STREET
FACILITY NUMBER: 198603511
VISIT DATE: 08/22/2025
NARRATIVE
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Documents showed that C1 had a visit with the primary physician on 11/13/24 for hypersalivation and cough. Lab work was also received; however, there were no signs of infection noted on C1s lab work. On 11/26/24, staff observed C1 had a change of condition and was not responding well and was hard to stimulate by the afternoon. C1 was taken to the hospital on the same day. C1’s hospital records revealed that C1 was being treated for diabetes’ related health issues and preexisting health conditions.

Per administrator and staff interviewed, the C1's physician was provided with the blood sugar level records and reviewed by the physician during medical visits. Staff indicated C1's physician did not mention anything regarding C1's blood sugars levels being elevated. C1's medications were given to C1 as prescribed. Staff were also monitoring C1 for any condition changes and ensuring C1 attended medical appointments as scheduled. Although C1's medical record indicated that C1 sustained an infection(s), there is no evidence to support that the infection was caused by C1's elevated blood sugar levels.

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; therefore, the allegation is UNSUBSTANTIATED.



An exit interview was conducted with Administrator. A copy of this report, along with the appeal rights, was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5