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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610130
Report Date: 10/04/2022
Date Signed: 10/04/2022 11:30:40 AM

Document Has Been Signed on 10/04/2022 11:30 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - BAIRDFACILITY NUMBER:
197610130
ADMINISTRATOR:FREEMAN, ELIZABETHFACILITY TYPE:
735
ADDRESS:10426 BAIRD AVETELEPHONE:
(818) 363-3333
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 4CENSUS: 4DATE:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Elizabeth FreemanTIME COMPLETED:
11:40 AM
NARRATIVE
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LPA Tihesha Smith met with Elizabeth Freeman (administrator) on 09/22/2022 for an investigative visit and during the course of the investigation other citations were revealed to be in deficiency.

A tour of the physical plant was completed no immediate health risks and safety risks observed during the day of visit.

LPA Smith interview with administrator revealed that an incident involving a client and staff was not reported or was not properly reported to include the Department. The administrator admitted that reporting requirements were not followed.

Citation issued. Appeal rights discussed and given.


Exit interview conducted. Copy of this report given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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Document Has Been Signed on 10/04/2022 11:30 AM - It Cannot Be Edited


Created By: Tihesha Smith On 10/04/2022 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - BAIRD
FACILITY NUMBER: 197610130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2022
Section Cited
CCR
80061(b)(2)

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Reporting Requirements- Written report shall be submitted to the licensing agency within seven days following the occurrence of such event.
This requirement was not met as evidenced by:
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Administrator will send written statement that all incidents will be reported in the required timeframe.POC due date: 10/05/22
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Based on Administrators' admission that facility failed to submit written incident report and report was never submitted which posed a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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