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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610130
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:46:14 PM

Document Has Been Signed on 01/10/2025 02:46 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: 1DATE:
01/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:49 PM
MET WITH:Jonathan Watts- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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In conjunction with the complaint number 31-AS-20230811124356 Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, it was confirmed that facility staff did not complete and submit the required SOC 341 Report of Suspected Adult/Elder Abuse as a part of Assembly Bill 40(AB40) requirements. Per the records review, R1 sustained injuries during a physical altercation with R2. Facility staff was reminded to complete and submit SOC 341 upon suspecting any abuse at the facility.

Exit Interview Conducted. Deficiencies Cited. Report Issued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 01/10/2025 02:46 PM - It Cannot Be Edited


Created By: Mariana Agban On 01/10/2025 at 01:52 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: 01/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2025
Section Cited
CCR
87211(c)

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87211(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours
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Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how will ensure that incidents are reported to all competent authorities.
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 as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: facility that did not complete and submit the SOC 341 Report of Suspected Adult/Elder Abuse as a part of Assembly Bill 40(AB40) requirements.
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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: 01/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2025


LIC809 (FAS) - (06/04)
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