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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201048
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:18:38 PM

Document Has Been Signed on 03/28/2024 03:18 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
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: 25DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:DELLA BOUGHTONTIME COMPLETED:
03:30 PM
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On 03/28/24 at 2:00 pm Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Administrator Della Boughton and explained the purpose of the visit.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the activity spaces, offices, med rooms, kitchens, bathrooms, and storage rooms. There is a comfortable room temperature of 70 degrees Fahrenheit for clients in care. Centrally stored medications, toxins and sharp objects were locked and inaccessible to participants. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 3/21/2024.

At 2:12 pm LPA reviewed 5 residents records. At 2:45 pm, LPA reviewed 3 staff records and 3 of 3 were fingerprint cleared and associated to the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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