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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610132
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:36:03 PM

Document Has Been Signed on 04/03/2023 02:36 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 - 27TH STREETFACILITY NUMBER:
197610132
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:43778 27TH STREET WESTTELEPHONE:
(661) 726-0663
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
04/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Moshood IbrahimTIME COMPLETED:
02:50 PM
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On 04/03/2023 at 10:00 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA observed appropriate Covid-19 postings on the outside wall by the front door. LPA was greeted by staff #1 (S1) and granted access. S1 requested LPA check temperature on temperature reader affixed to the entry wall. S1 recorded temperature and asked LPA to sign in then directed LPA to wash their hands. S2 called the Administrator Moshood Ibrahim using the facility’s telephone and notified Administrator LPA was at the facility. LPA explained the reason for the visit. Administrator met LPA shortly after.

At 10:30 a.m. LPA conducted interviews with three (3) out of three (3) staff and three (3) out of four (4) clients present. The fourth client was not present at the facility. Clients and staff were on their way out to do their weekly grocery shopping. At 11:35 a.m. LPA, S1 and the administrator toured the physical plant of the facility, and the following was observed.

Kitchen/ Dinning area: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked under the kitchen sink. 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. LPA observed one fridge in the kitchen with a grocery shopping list on the fridge. S2 stated a second fridge and freezer are in the garage and grocery shopping is done every Monday or as needed at the end of the week. On one of the kitchen's walls LPA observed one (1) out of two (2) fire extinguishers fully charged with a last serviced date of 10/19/2022. Dining area had appropriate table and chairs to sit the capacity of the facility.

At 11:47 a.m. LPA observed Administrator test a dual smoke and carbon monoxide detector. Detector is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly. (Continued on to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 - 27TH STREET
FACILITY NUMBER: 197610132
VISIT DATE: 04/03/2023
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(Continued LIC809-C) Living room: The living room was clean and properly furnished. Fireplace not in use 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, beddings and with sufficient lighting and storage. LPA observed extra linens in a hallway outside the bedrooms and a second fire extinguisher fully charged last serviced 10/19/2022.

Bathrooms: The facility has 2 bathrooms. The LPA took water temperature from one (1) out two (2) bathrooms sink and temperature was between 105 and 120 degrees F. LPA observed the bathrooms to be clean and properly supplied with toilet paper, paper towels and trash bins with lids.

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. One pharmacy is being utilized for resident use. Refills are either done automatically every 30 days, or ordered by the physician. Medication Records were reviewed for proper documentation. Medication records are maintained both electronically and manually.

Laundry/Garage: Laundry area is located in the garage. Garage is accessible to clients and staff. Detergents are kept locked in a cabinet above the laundry. LPA observed one fridge and a freezer with food.

Surrounding Grounds: Entry and exits were free of obstruction. There is a covered patio with appropriate furniture for clients to use. LPA also observed exercise equipment for clients to use. There is a large shed that was locked and being used to store extra facility supplies. S2 stated they have enough PPE to last more than 30 days.

Client/Staff Records: At approximately 12:15 p.m. four (4) out four (4) client records and (3) staff records were reviewed to insure compliance.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC809 (FAS) - (06/04)
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