331881068-6-26-2024-18-AS-RSTS-D6NRZ5-20240628132722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881068
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:29:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
06/12/2024 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20240612120032

FACILITY NAME:	REM CALIFORNIA LLC - BAXTER		FACILITY NUMBER:	331881068
ADMINISTRATOR:	SIBANDE, CAROLINE		FACILITY TYPE:	735
ADDRESS:	13508 BAXTER COURT		TELEPHONE:	(951) 247-4555
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	4	CENSUS: 4	DATE:	06/26/2024
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Administrator, Caroline Sibandae		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff handled resident in a rough manner resulting in bruising
Facility staff forced resident to take medicine

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator, Caroline Sibandae and explained the purpose of the visit. The investigation consisted of observation, interviews with staff members and residents, and records review.
On 06/12/2024, Community Care Licensing received a complaint alleging that Facility staff handled resident in a rough manner resulting in bruising and Facility staff forced resident to take medicine. It was reported that on 6/12/24, between 8am-9:15am, a staff member held down Resident #1 (R1) in order to get them to take their medications. During the investigation, LPA observed R1 with a bruise on their left arm. Information obtained from interviews with R1 indicated that the bruise occurred from a fall. Administrator stated that they are unclear on the origin of R1’s bruise. Administrator stated that R1 has previously obtained bruises from sitting in one spot too long or bumping into walls. Administrator denied that the staff member gave the resident a bruise. Information obtained from interviews with staff members, stated due to R1’s medical condition, R1 bruises pretty easily. It was advised that R1 can get the bruises from sitting in one position for a long period of time due to R1’s medical condition. Information obtained from an interview with Staff Member (S1) stated that they did not handle the resident in a rough manner causing a bruise. S1 also stated that the origin of the bruise is unknown.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240612120032

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REM CALIFORNIA LLC - BAXTER	FACILITY NUMBER: 331881068
	VISIT DATE: 06/26/2024

NARRATIVE

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In regards to the allegation that facility staff force residents to take medication, LPA interviewed R1, but was unable to obtain any specific information regarding medication distributed. Information obtained from Administrator indicated there have not been any concerns regarding R1 being force to take medications. Information obtained from interviews with staff members regarding management of resident’s medication advised that residents are not forced to take medication. It was advised that residents are able to refuse and staff are obligated to document refusals. In regards to R1, R1 often refuses due to medications being passed while R1 is still asleep; therefore, R1’s physician has allowed a two hour window for medication distribution in order to diminish R1’s refusals. During record review, LPA reviewed the R1’s medication and all medications appeared to have been logged and distributed accurately for the months reviewed.

In regards to both allegations, LPA spoke with Inland Regional Center, Consumer Program Liaison Specialist for R1. Liaison Specialist indicated the information obtained corroborated the information they received during their investigation.

Based on information obtained through interviews and record review, the allegations that facility staff handled resident in a rough manner resulting in bruising and facility staff forced resident to take medicine are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted and a copy of this report was provided to Administrator, Caroline Sibande.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

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