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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610132
Report Date: 04/16/2025
Date Signed: 04/16/2025 04:38:21 PM

Document Has Been Signed on 04/16/2025 04:38 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/
DIRECTOR:		IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:43778 27TH STREET WESTTELEPHONE:
(661) 726-0663
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Moshood Ibrahim (Program Director)TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 04/16/2025 at 12:45 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by staff and granted access. Staff requested LPA to sign in. LPA met with the Program Director (PD), Moshood Ibrahim. LPA explained the reason for the visit.

At 12:50 p.m. LPA Rios and staff #1 (S1) toured the physical plant of the facility, and the following was observed.

LPA inspected four (04) out of four (04) client bedrooms. Bedrooms are for private use. LPA observed each client room to be properly furnished and with sufficient lighting and storage. LPA observed a fire extinguisher fully charged with a last serviced date 09/18/2024 in the hallway by the bedrooms. LPA observed two (02) carbon monoxide detectors in the hallway leading to the bedrooms. Detectors were tested and operating properly. Three (03) clients were getting ready for an outing and one (01) client was out in the community.

The facility has two (02) bathrooms. Hot water temperature was taken from the bathroom closest to the bedrooms at 3:20 p.m., and read 113.9 degrees Fahrenheit, within regulation. LPA observed the bathrooms to be clean and properly supplied with toilet paper, paper towels and trash bins with lids.

Laundry area is located in the garage. Garage is accessible to clients and staff. Detergents are kept locked in a cabinet next to the washer and dryer. LPA observed one fridge and a freezer with extra food. LPA also observed two (2) emergency kits and emergency water. (Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
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: 04/16/2025
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LPA toured the backyard and observed entry and exits were free of obstruction. There is a covered patio with appropriate outdoor furniture. LPA also observed exercise equipment for clients. LPA observed a shed that was locked and being used to store extra facility supplies. No bodies of water observed.

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 sharps 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 a second fire extinguisher fully charged with a last serviced date of 09/18/2024. Dining area had a table with chairs to sit the capacity of the facility.

The living room was clean and properly furnished with couches and recliners to sit the capacity of the facility. LPA observed a television and facility telephone accessible to clients.

LPA observed smoke detectors through out the facility, detectors are hard wired and interconnected. At 1:06 p.m., LPA observed the PD test a smoke detector. Detectors were observed to be functioning properly.



At 1:10 p.m., centrally stored medications were observed locked in a medication cart by the kitchen and dining area. LPA and staff #2 (S2) reviewed clients' medication and medication records. LPA also reviewed facility's infection control plan, emergency disaster plan (LIC610D) and facility's emergency disaster binder. Facility last conducted a fire drill on 03/03/2025 and an earth quake drill on 03/12/2025 with all staff on different shifts.

From 3:00 p.m. to 3:53 p.m., LPA reviewed four (04) of four (04) client records for compliance with licensing forms. At 3:44 p.m, LPA reviewed four (04) staff records for compliance with licensing forms and up-to-date training. No issues observed.

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.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
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