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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610130
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:21:40 PM

Document Has Been Signed on 07/03/2024 04:21 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - BAIRDFACILITY NUMBER:
197610130
ADMINISTRATOR/
DIRECTOR:		FREEMAN, ELIZABETHFACILITY TYPE:
735
ADDRESS:10426 BAIRD AVETELEPHONE:
(818) 363-3333
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 4CENSUS: 3DATE:
07/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Idris DanesiTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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In conjunction to the complaint number 31-AS-20240628090950 Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit. LPA received a Special Incident Report from S2 regarding an incident on 3/10/24. S2 reported that facility staff failed to report the incident to S2 in a timely manner and thus S2 submitted the Special Incident Report to CCL promptly.


Exit Interview Conducted. Deficiencies Cited. Report Issued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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Document Has Been Signed on 07/03/2024 04:21 PM - It Cannot Be Edited


Created By: Mariana Agban On 07/03/2024 at 02:29 PM
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: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2024
Section Cited
CCR
80061(a)(1)

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80061. Reporting Requirements. (a) Each licensee shall furnish to the licensing agency reports as required by the Department, (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day. A written report …shall be submitted to the licensing agency within seven days following the occurrence of such event.

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Administrator emalied LPA and CCL the Incident Report.
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This requirement is not met as evidenced by: The Licensee did not report unusual incident in a timely manner. This may potentially affect health, safety and wellbeing of clients.
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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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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