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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610131
Report Date: 10/11/2024
Date Signed: 10/11/2024 05:36:49 PM

Document Has Been Signed on 10/11/2024 05:36 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 - DESERT HILLSFACILITY NUMBER:
197610131
ADMINISTRATOR/
DIRECTOR:		IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:8241 WEST AVENUE C-14TELEPHONE:
(818) 415-4301
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
10/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Perpetua Asombang TIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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On 10/11/2024 at 2:00 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by the administrator designee, Perpetua Asombang and granted access. Perpetua called the Administrator Moshood Ibrahim. LPA explained the reason for the visit. Administrator met LPA shortly after.

At 2:25 p.m. LPA, with the administrator designee toured the physical plant of the facility, and the following was observed.

Living Room: LPA observed a spacious living area with a couch and recliner that sits the capacity of the facility. LPA observed a large television and a fireplace secured with a screen.

Bedrooms: LPA inspected four (4) out of four (4) client bedrooms. Bedrooms are for private use. LPA observed each client room to be properly furnished with one bed, appropriate night stand, chair, bedding and with sufficient lighting and storage. LPA observed extra linens and client toiletries in a hallway cabinet. LPA observed a locked hallway closet used to store cleaning supplies.

Bathrooms: The facility has three (3) bathrooms. LPA observed the bathrooms to be clean and properly supplied with toilet paper, paper towels and trash bins with lids.

Laundry/Garage: Laundry area is accessible to clients and detergent are maintained locked in the cabinets. The garage is accessible through the office. LPA observed one fridge and a freezer with extra food. Facility also stores emergency food and water in the garage.

Surrounding Grounds: Entry and exits were free of obstruction. There is a covered patio with appropriate furniture for clients to use. (Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - DESERT HILLS
FACILITY NUMBER: 197610131
VISIT DATE: 10/11/2024
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Kitchen/ Dinning area: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed knives locked in a bottom cabinet within a locked tool chest. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food at the facility; properly stored. By the kitchen LPA observed one (1) out of two (2) fire extinguishers fully charged with a last serviced date of 09/18/2024. Dining area had appropriate table and chairs that sits the capacity of the facility.
At 2:30 p.m. LPA observed staff test a smoke and carbon monoxide detector. Smoke detectors are hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly.

Client Files: At approximately 2:39 p.m. LPA reviewed resident files. LPA conducted a file review of four (4) out of four (4) resident records to insure compliance of licensing forms.

Medications: Centrally stored medications are maintained in a locked medication cart by the kitchen and dining area. Medications were observed locked in the medication cart. LPA and Administrator went over medication and medication records. Facility keeps Medication Administration Records (MARs) electronically. Pharmacy provides Centrally Stored Administration and Destructions Records to facility. Facility has two fully supplied first aid kits with manual.

Staff Records: At 4:22 p.m. LPA also conducted a file review of four (4) out of nineteen (19) staff records to insure forms and training are up to date and in compliance with licensing forms. LPA reviewed emergency disaster training, LIC 500 and infection control plan. LPA discussed resident care plan with administrator designee.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, there were no deficiencies observed during today's visit. Exit interview conducted. A Copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
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