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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610132
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:41:01 PM

Document Has Been Signed on 03/20/2024 02:41 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
WOODLAND HILLS S.RO, 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:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Moshood IbrahimTIME COMPLETED:
01:31 PM
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At 09:30 a.m. Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility listed above to conduct an unannounced annual inspection. 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. S1 advised LPA that Administrator Moshood Ibrahim would be arriving shortly. LPA explained the reason for the visit. Administrator met LPA shortly after.

At 10:05 a.m. LPA 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. LPA observed one fridge in the kitchen with a grocery shopping list on the fridge. LPA observed one (1) out of two (2) fire extinguishers fully charged with a last serviced date of 09/29/2023. Dining area had an appropriate table and chairs to sit the capacity of the facility.

Living room: The living room was clean and properly furnished. Fireplace not in use secured with a screen. At 10:22 a.m. LPA observed Administrator test a dual smoke and carbon monoxide detector. Detectors were observed to be functioning properly.

Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - 27TH STREET
FACILITY NUMBER: 197610132
VISIT DATE: 03/20/2024
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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 nightstand, chair, bedding 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 09/29/2023.

Bathrooms: The facility has 2 bathrooms. Water temperature was 112 degrees F. 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 located in the garage. Garage is accessible to clients and staff. Detergents are kept locked in a cabinet next to the laundry machines. LPA observed one fridge and a freezer with extra 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.

Client/Staff Records: At approximately 11:00 a.m. four (4) out four (4) client records and (3) staff records were reviewed to ensure compliance.

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.

Staff Interviews: At 12:30 p.m. LPA conducted interviews staff.

Client Interviews: At 12:00 p.m LPA interviewed clients present.

No citations issued. Exit Interview Conducted. A Copy of this report given to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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