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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610132
Report Date: 01/21/2022
Date Signed: 01/21/2022 11:47:24 AM

Document Has Been Signed on 01/21/2022 11:47 AM - 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 - 27TH STREETFACILITY NUMBER:
197610132
ADMINISTRATOR:DAY, DANSHELLEFACILITY TYPE:
735
ADDRESS:43778 27TH STREET WESTTELEPHONE:
(818) 363-3333
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 3DATE:
01/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Moshood Ibrahim ,AdministratorTIME COMPLETED:
12:00 PM
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At 10:05 am, Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced Case Management visit at the facility mentioned above. The purpose of this visit was in relation to an incident report regarding a client (C1). Upon entry, LPA was greeted by the Caregiver, Jacqueline Harper. The Administrator, Moshood Ibrahim arrived at approximately 10:38am. The purpose of this visit was explained, and a physical plant tour was conducted.

LPA interviewed C1 and the Administrator. LPA reviewed C1's facility file, and obtained copies of pertinent information related to the incident. Due to the need for more information this Needs Further Investigation. Exit Interview conducted and report delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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