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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610131
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:22:21 PM

Document Has Been Signed on 08/27/2021 12:22 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - DESERT HILLSFACILITY NUMBER:
197610131
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:8241 WEST AVENUE C-14TELEPHONE:
(818) 415-4301
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 1DATE:
08/27/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mooshood Ibrahim TIME COMPLETED:
12:25 PM
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Licensing Program Analysts LaQueena Lacy conducted an announced Pre-Licensing visit to this facility and met with applicant Moshood Ibrahim. This is a change of ownership application from 197609940 to 197610131, the applicant REM California, LLC. Fire Clearance dated 06/25/2021 was received for four (4) non-ambulatory clients.

Entrance Interview conducted with the administrator and explained the purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of the LPA touring the physical plant inside and outside and the following was observed:

The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette) posted. The PPE screening is conducted upon entrance at the front door. Sufficient PPE is readily kept on the table near the entrance, the thermometer is wall mounted, hand sanitizer, gloves, mask, and sign in sheet located at the front door at the time of visit

The facility is a single-story home, it has four (4) bedrooms designated for residents, which were observed to be clean and appropriately furnished and equipped with adequate lighting. The facility has two and a half (2.5) bathrooms in which two are designated for resident use. At 9:48am all bathrooms were observed to have non-skid mats and appropriate grab bars installed and all trash cans contain lids. At 10:03am hot water was tested in the common bathrooms and measured in range of 105.9 to 110.8 degrees F. There is a functioning telephone on the premises. The emergency exit plan/sketch is posted by the entrance of the facility on the wall with other posting requirements. The facility has place auditory alarms on all exit doors. The common areas (living room and dining areas) were appropriately furnished and lighting is adequate. The living room has a television, side tables and comfortable furniture for seating which was observed to be in good repair.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - DESERT HILLS
FACILITY NUMBER: 197610131
VISIT DATE: 08/27/2021
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A fireplace is also in the living room but is not being used due to the house being centrally heated and air conditioned. Kitchen appliances observed to be in good repair and functioning. At 10:17am Sharps were observed to be locked in a kitchen cabinet under the counter stored in a locked Sentry Safe. Medications were observed at 10:30am to be locked and stored in the kitchen in a locked storage room. The facility has three (3) first aid kits and manual readily available and observed to be stored in the locked medication cabinet storage. The Laundry room is located adjacent to the office and kitchen. The laundry supplies, cleaning supplies and toxins were observed to be stored and locked in a cabinet above the counter in the laundry room. Extra linen and towels are stored in the laundry room. Resident and staff records are stored in the Office adjacent to the kitchen which was observed to be locked and clean and clear from obstruction.

The facility has an attached garage and the entrance is gained through the office, It has a dual side storage cabinet observed locked and stocked with an adequate quantity of PPE, extra cleaning supplies, and emergency food kit tubs readily and accessible to staff when needed. The facility has two (2) days of perishable and seven (7) days non-perishable food and an extra refrigerator with appropriately labeled and packaged food and vegetables.

At 10:38am the Backyard was observed to be clean and clear from obstruction. It has a shaded covered patio area with a table and owning for seating, outdoor furniture observed to be clean and in good repair. The back yard is enclosed with a gated locked fence and no bodies of water observed on the property. The front yard is clean and clear from obstruction also equipped with outdoor furniture in good repair for seating under a covered shaded area.

The fire extinguisher is located on the wall near the hallway in the living room and the kitchen wall between the office observed to have a service tag of 12/09/2020. At 10:51am the facility smoke alarm was tested and observed to be operational and functioning properly. The facility has a Carbon Monoxide detector plugged in the wall in the kitchen near the start of the living room which was tested at 11:07am observed to be functioning properly. The facility appears to be clean and in good repair and observed to be a comfortable temperature of 71 degrees F. which is within regulation.

Component III was conducted with the administrator.


Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and you will be notified by the CAB Analyst when your license has been approved.
Exit interview was conducted with Licensee Representative Moshood Ibrahim and a copy of this report was provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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