425850134-12-12-2024-29-AS-KBUY-DC9PKV-20241224102346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850134
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:45:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2024 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20241121103917

FACILITY NAME:	REM CALIFORNIA LLC - LOMPOC		FACILITY NUMBER:	425850134
ADMINISTRATOR:	SMITH, RONICA		FACILITY TYPE:	775
ADDRESS:	1133 NORTH H STREET SUITE F		TELEPHONE:	(805) 757-9595
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	45	CENSUS: 10	DATE:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ronica Smith, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff physically abused resident in care
Staff caused injury to resident in care

INVESTIGATION FINDINGS:

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On 12/12/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint investigation visit to the facility above. LPA arrived at the facility, met with administrator Ronica Smith, and announced the purpose of the visit.

On the allegation: Staff physically abused resident in care. It is alleged that when Client #1 (C1) became upset and aggressive towards facility staff, Staff #1 (S1) kicked C1 in the stomach and scratched both of C1’s arms.

On 09/23/2024, the Licensing Agency received a self-reported Unusual Incident/Injury Report (UIR) regarding client #1 (C1) alleging that they caused self-harming behavior on 09/19/2024, during an outing in the community supervised by facility staff. The UIR noted that on 09/19/2024, facility staff escorted clients to a local gym within walking distance of the facility. C1 was encouraged to use the restroom before clients left the facility and they did according to the UIR. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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 29-AS-20241121103917

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - LOMPOC	FACILITY NUMBER: 425850134
	VISIT DATE: 12/12/2024

NARRATIVE

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Facility staff and clients were at the gym 10 minutes when C1 went to the restroom at the gym. When C1 came out staff encouraged them to minimize use of the restroom at the gym because they were spending about 15 to 20 minutes in there unsupervised. Staff were unable to supervise C1 while in the restroom due to the gym being open to the public and utilizing segregated men’s and women’s restrooms. As all staff supervising the clients at the gym were female, they could not enter the male segregated gym bathroom to supervise male clients. Upon exiting the restroom and being spoken to by facility staff, C1 began to experience behavioral issues including physical and verbal aggression. C1 began hitting and biting themselves and said they were leaving the gym to walk home. According to the UIR, S1 told C1 to wait for the rest of the clients which caused C1 to start swinging punches attacking S1. This behavior by C1 continued all the way back to the facility where C1’s relatives were waiting. According to the UIR, C1 went on to attack their relatives physically and verbally. Staff interviewed by LPA stated that sometimes when C1 gets very upset they self-harm including pulling on their own ears very hard and biting themselves very hard. C1 will also begin to shake uncontrollably. Staff stated that S1 is usually able to calm C1 down, but during this incident they observed C1 displaying physical signs of behavioral issues. Staff stated to LPA that during the incident involving C1, they saw S1 at the gym attempting to block themselves from the punches being thrown by C1 but did not see S1 use any type of physical aggression. The facility Preplacement Appraisal Information for C1 states that C1 has a history of mental/emotional behaviors resulting in harm to self and others including verbal and physical aggression. Documented behavioral services agency evaluations for C1 stated that C1 has exhibited several instances of verbal outbursts/yelling and needs space and/or isolation. Evaluations for C1 also state that traditional reinforcements for good behaviors can cause C1 frustration and escalation. Outside agency Individual Program Plans (IPP) and psychological evaluations/behavior support plans for C1 indicate that C1 has frequent behavioral issues including verbal outbursts/yelling, as well as physical aggression/self-injurious behavior including pushing, biting, hitting, kicking others, and biting and/or hitting themselves. Based on the information gathered, there is insufficient evidence to prove S1 physically abused C1. Therefore, the allegation is Unsubstantiated.

On the allegation: Staff caused injury to resident in care. It is alleged that C1 had scratches on their neck and arms as well as ripped skin behind their ear due to the alleged incident of physical abuse by S1.

Through interviews with facility staff and record review of C1’s relevant documentation, LPA learned that when C1 gets very upset they can experience episodes of physical self-harm including pulling on their own ears very hard and biting themselves very hard. Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20241121103917

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - LOMPOC	FACILITY NUMBER: 425850134
	VISIT DATE: 12/12/2024

NARRATIVE

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C1 has a history of mental/emotional behaviors resulting in harm to self and others including verbal and physical aggression. C1 has exhibited several instances of behavioral issues including verbal outbursts/yelling, as well as physical aggression/self-injurious behavior including pushing, biting, hitting, kicking others, and biting and/or hitting themselves. C1 has a documented history of physical aggression/self-injurious behavior during escalated outbursts such as the incident on 09/19/2024 self-reported by the facility in UIR and stated by staff when interviewed by LPA. According to C1’s behavioral support plans, IPPs, and psychological evaluations, they tend to have behavioral outbursts when hearing that they cannot do something or that something they want is unavailable. In this incident, C1 began to have a behavioral outburst leading to self-injurious behaviors when told by Staff to minimize using the restroom at the gym the clients were taken to by Staff. However, even though there is insufficient evidence to prove that S1’s physical abuse of C1 occurred or caused injuries to C1, S1 was disciplined by the Licensee/facility for violations of verbal Crisis Prevention Intervention (CPI) policies and procedures. The licensee conducted an internal investigation that substantiated allegations against S1 for violations of client rights and not following CPI regarding C1 during the 09/19/2024 incident. The corrective action plan for S1 undertaken by the licensee was to have S1 participate in the retraining of CPI, person centered policies and procedures, and retraining of client rights. On 11/25/2024, LPA was provided with copies of the training documentation for S1 showing that S1 had completed the necessary training listed by the Licensee in the corrective action plan. However, based on the information gathered, there is insufficient evidence to prove S1 caused physical injuries to C1 due to physical abuse by S1. Therefore, the allegation is Unsubstantiated.

Exit interview conducted by the LPA. Copy of this report provided to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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