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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881066
Report Date: 08/26/2021
Date Signed: 08/26/2021 09:59:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2021 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210405083733
FACILITY NAME:REM CALIFORNIA, LLC - SKYLANDFACILITY NUMBER:
331881066
ADMINISTRATOR:FLORENCE, TAMARAFACILITY TYPE:
735
ADDRESS:24795 SKYLAND DRTELEPHONE:
(951) 601-3444
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:4CENSUS: 3DATE:
08/26/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Christine RossTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Staff engaged in a physical altercation with client resulting in injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to deliver the finding of the above allegation. LPA met with DSP Christine Ross. LPA spoke with the administrator over the phone.

LPA toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that on 3/31/21 Staff 1 (S1) engaged in a physical altercation with Client 1 (C1) which resulted in injuries. LPA observed that the licensee submitted a special incident report on 4/1/21 in regards to the incident. During the file review and interviews, LPA was informed that C1 allegedly AWOL’ed from the facility and returned after being redirected by staff. Upon his/her return, C1 began exhibiting behaviors and started to become aggressive towards the staff. S1 took C1 back to the client’s room where they engaged in a physical altercation. According to a witness statement, C1 shoved S1 and in response S1 lost control and pushed the client back. C1 fell and sustained injuries such as lacerations on the neck. Another staff member rendered first aid for C1 and the facility called 911 to file a police report and have C1 transported to the
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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 18-AS-20210405083733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: REM CALIFORNIA, LLC - SKYLAND
FACILITY NUMBER: 331881066
VISIT DATE: 08/26/2021
NARRATIVE
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hospital for his/her injuries. This poses an immediate health, safety, & personal rights risk to the clients in care. During the investigation, LPA was informed that the facility terminated S1’s employment after the incident.

Based on LPA’s observations and interviews, which were conducted, 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 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to the DSP.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210405083733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REM CALIFORNIA, LLC - SKYLAND
FACILITY NUMBER: 331881066
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited
CCR
80072(a)(3)
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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: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or
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The licensee shall conduct in-service training to direct care staff in regards to the clients’ personal rights. Proof will be submitted to the Department by 8/27/21.
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other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met evidenced by: Based on file review & interviews, the
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DEF CONT'D licensee did not ensure C1’s personal rights were protected. On 3/31/21, S1 & C1 got into a physical altercation where S1 pushed C1 which resulted in C1 falling and sustaining injuries. Facility staff called 911 where C1 was treated for his/her injuries.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3