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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610131
Report Date: 02/24/2025
Date Signed: 02/24/2025 04:00:52 PM

Document Has Been Signed on 02/24/2025 04:00 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: 3DATE:
02/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Perpetua Asombang / Program DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 02/24/2025 at 3:15 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct a Case Management - Incident visit in conjunction to complaint control #31-AS-20250113152315. LPA was granted entry by staff. LPA met with the Program Director, Perpetua Asombang and LPA explained the reason for the visit was to follow up on a Special Incident Report (SIR) submitted to CCLD on 01/29/2025.
SIR states, the facility received information that it is being alleged staff #1(S1) requested, Client #1 (C1), to lie about another staff #2(S2) in the facility. LPA interviewed Program Director who provided information about the report. C1 is no longer at the facility. Facility is conducting an internal investigation. Reporting requirements met by facility for incident. No citations issued at this time. LPA explained to Program Director they may return to the facility unannounced if CCLD receives further information.

Copy of report provided and delivered
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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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