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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610132
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:06:36 PM

Document Has Been Signed on 03/11/2022 12:06 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 - 27TH STREETFACILITY NUMBER:
197610132
ADMINISTRATOR:DAY, DANSHELLEFACILITY TYPE:
735
ADDRESS:43778 27TH STREET WESTTELEPHONE:
(818) 363-3333
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amparo Murvin TIME COMPLETED:
12:15 PM
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At 10:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by a staff member. LPA was informed that the Administrator, Moshood Ibrahim was not available during today’s visit. LPA met with Amparo Murvin, Program Director. Entrance interview was conducted, and a physical plant tour was conducted at 10:25 a.m. and the following was observed:

Infection control: Upon arrival, LPA observed infection control postings outside of the facility. Upon entrance, staff asked LPA to sign in the visitor’s log, LPA’s temperature was taken, a covid-19 questionnaire was given to LPA. Lastly, LPA was directed to wash hands with soap and water. Program Director stated they have sufficient PPE supplies for clients and staff.

Smoke detectors/carbon monoxide were located throughout the facility and deemed to be in operating condition. Fire extinguisher has a date of service of 12/15/2021.

Resident rooms: There are four (4) bedrooms, all designated for client use. All client bedrooms were properly furnished with appropriate bedding, sufficient lighting, and the room appeared to be clean. Trash cans with lids were observed.

Bathrooms: There are two (2) bathrooms for staff and clients. LPA Ruiz observed appropriate hand washing signs posted in the bathroom.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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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 - 27TH STREET
FACILITY NUMBER: 197610132
VISIT DATE: 03/11/2022
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Paper towels were available and trash cans have closed tight fitting lids.

Kitchen: LPA observed the kitchen to be clean and inaccessible to pests. Sharps and cleaning solutions are kept locked in kitchen cabinets. LPA observed sufficient food supply. Medications are centrally stored and locked in a medication cart near the kitchen.



Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients.

Administrative: LPA conducted a facility file review and noted that there was no notification given to the Woodland Hills Regional Office regarding a change of Administrator. LPA advised the Program Director to submit documentation no later than 3/18/2022. The following documents were requested:

· LIC200
· LIC308
· LIC500
· LIC501
· LIC508
· Board Resolution naming the new Administrator
· Administrator Certificate
· First Aid/CPR Certificate
· Emergency contact phone number and e-mail.

No deficiencies were issued during today’s visit. Exit interview conducted. Report was signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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