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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201048
Report Date: 02/01/2023
Date Signed: 02/01/2023 11:47:01 AM

Document Has Been Signed on 02/01/2023 11:47 AM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REM CALIFORNIA LLC - ASHLANDFACILITY NUMBER:
019201048
ADMINISTRATOR:DELLA BOUGHTONFACILITY TYPE:
775
ADDRESS:29800 MISSION BLVDTELEPHONE:
(510) 278-3937
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 60CENSUS: 9DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Della Boughton, Program DirectorTIME COMPLETED:
11:55 AM
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On 2/1/23 at 11:05 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Infection Control Inspection. LPA met with Della Boughton, Program Director and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to: front entrance, screening station, bathrooms, common areas and kitchen. There is one central entry point for universal screening for staff, participants and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPE maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for participants and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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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