425850135-9-25-2024-29-AS-EMIR-D9FT8G-20240925143019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850135
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:30:26 PM

Document Has Been Signed on 09/25/2024 02:30 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	REM CALIFORNIA LLC - CHURCH		FACILITY NUMBER:	425850135
ADMINISTRATOR/ DIRECTOR:	SALAZAR, RAQUEL		FACILITY TYPE:	775
ADDRESS:	305 WEST CHURCH STREET		TELEPHONE:	(805) 349-7516
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 45		CENSUS: 15	DATE:	09/25/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Raquel Salazar, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Erika Miller and Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miguel Magaña conducted an unannounced case management visit to follow up on an incident that occurred with Client 1 (C1) on 9/17/24. LPA met with Raquel Salazar, (Administrator) and explained the purpose of the visit. On 09/18/24, Administrator received an email from Calista Koska (Koska) Program Coordinator from C1 residence. C1 alleged on 9/17/24, a Day Program staff "hit him in the back of the head". Staff 1 (S1) was identified as the attendant on duty at the time of the alleged incident and was suspended from duties effective 9/18/24. Quality Improvement Specialist (QI), Lupe Ramirez at Day Program conducted an internal investigation. The investigation was concluded on 9/23/24 and S1 returned to work on 9/24/24. A copy of the report is not available but will be provided later. LPA and QA interviewed clients and staff that were present at that the time of the incident on 9/17/24.C1 denied that they made an allegation that S1 hit him in the back of the head. C1 explicitly stated that S1 did not hit him. C1 further stated that staff and peers treat him well. S1 refuted C1’s allegation in its entirety and stated they would never put hands on a client. S1 further stated that they were siting in the back of the van and not near C1, who was in the front seat. S2 works alongside S1 and stated they have never observed S1 hit C1 or any other client. S3 stated that C1 did not have any behaviors last week and had no issue getting onto the van the day of the incident. S3 stated that C1 did not complain about any incidents in the van.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: REM CALIFORNIA LLC - CHURCH	FACILITY NUMBER: 425850135
	VISIT DATE: 09/25/2024

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2 of 3 clients stated that are treated well by staff and peers and they have not observed staff hit clients. 1 of 3 staff appeared happy and also stated that they like staff.

LPA and QA also interviewed Koska who stated that they observed C1 leaving the bus on 9/17/24. Koska stated that C1 appeared happy and gave S1 a high-five. Koska stated that C1 asked how they would feel if Day Program staff hit him. Upon further inquiry by Koska, C1 identified S1 as staff that hit him. Koska advised that thirty minutes later, C1 requested to work with S1 in the future and brushed it off as a minor incident. Koska explained that C1 has a Behavior Plan that includes C1’s making false accusations. Koska stated C1 has a history of not telling the truth, including to medical professionals.

No deficiencies were issued. Exit interview conducted and a copy of the report printed for administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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