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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610133
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:24:10 PM

Document Has Been Signed on 08/28/2024 01:24 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 - NAPAFACILITY NUMBER:
197610133
ADMINISTRATOR/
DIRECTOR:		IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:16214 NAPA STTELEPHONE:
(818) 892-2800
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Gboyega Akinbola- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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This case management visit is conducted by the Licensing Program Analyst (LPA) Leslie Ngo-Castaneda in conjunction with complaint investigation visit to address the issues related to the complaint. On 8.12.2024, conducted unannounced, subsequent visit to this facility in conjunction with a complaint control #31-AS-20240802122246. LPA met with the Administrator, Gboyega Akinbola and explained the reason for the visit.

On 8.12.2024 while LPA was conducting complaint investigation, LPA reviewed facility program and found on page 28 that facility needs to provide dietician services for two (2) hours per person per month. Upon record review, facility switch dietician from January 2024 to June 2024 leaving the clients not being seen for four (4) months.

Therefore, based on the record review and interview with administrator, it was concluded that the facility did not provide a dietician specialist for the month of February to June of 2024.

Under Title 22 Regulations, the following citation is issued and recorded on LIC809D. Deficiency will be cleared during today’s visit since a new dietician specialist was on-boarded on June 2024 and started providing services for the clients.

No immediate health and safety hazard is noted at the time of this visit. Exit interview was conducted. Appeal rights discussed and a copy of report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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
Document Has Been Signed on 08/28/2024 01:24 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 08/28/2024 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - NAPA
FACILITY NUMBER: 197610133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2024
Section Cited
CCR
85078(a)(1)

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Responsibility for Providing Care and Supervision: The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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The licensee was given a Correctivie Action Plan (CAP), to be completed by 09.11.20/24. As POC for Community Care Licensing (CCL), the licensee will submit a copy of this CAP to licensing also by 9.11.2024
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 Reports received by consultant services have not been provided to clients since January 2024. Moreover, the facility administrator was unable to verify how many hours of Registered Nurse consult services were provided per resident as required from the period of January through June 2024.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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