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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004018
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:49:46 PM

Document Has Been Signed on 10/14/2021 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA, LLC - BELLFLOWERFACILITY NUMBER:
306004018
ADMINISTRATOR:MANALASTAS, ALBERTOFACILITY TYPE:
735
ADDRESS:6129 BELLFLOWER BLVDTELEPHONE:
(562) 866-9634
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 4DATE:
10/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Alberto Manalastas - AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit in regards to a Special Incident Report that was submitted to Licensing on 10/07/2021. LPA met with Administrator Alberto Manalastas and explained the reason for the visit.

Per Incident Report on 10/06/2021, Staff #1 (S1) splashed water at Client #1 (C1). Administrator was talking to another client in his office when the incident occurred. C1 came rushing into the office with wet clothes and told the Administrator that S1 wet him. Administrator questioned S1 and S1 stated that C1 was laughing at him. Client #2 (C2) and Client #3 (C3) witnessed the incident.

During today's visit: LPA requested copies of staff and client roster, interviewed C1, C2, and C3, reviewed S1 facility file, and obtained a copy of the police report. Based upon the information obtained on today's visit, it has been determined that C1 personal rights were violated when S1 splashed water at C1. Clients reported that they have no issues with the other staff. On the day of the incident, the Administrator sent S1 home and S1 told the Administrator that he is not coming back. S1 has not worked since the day of the incident and an internal investigation is currently in process.

Deficiencies were cited under Title 22 Regulations. Exit interview was conducted with Administrator Alberto Manalastas and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2021 03:49 PM - It Cannot Be Edited


Created By: Luis Mora On 10/14/2021 at 02:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REM CALIFORNIA, LLC - BELLFLOWER
FACILITY NUMBER: 306004018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited
CCR
80072(a)(3)

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80072 Personal Rigjts. (a)...each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.....
This requirement is not met as evidence by:
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Administrator is to conduct personal rights training for all staff and send a copy of the training log to include the name of the trainer and all staff trained by POC due date 10/21/2021.
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Based on interviews and incident report submitted to the department it has been determined that Staff #1 splashed water at Client #1 which poses an immediate Health, Safety, or Personal Rights 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.
SUPERVISOR'S NAME:Rebecca Orendain
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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