197610133-2-11-2023-31-AS-TSMH-CNY26S-20230211160738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610133
Report Date: 02/11/2023
Date Signed: 02/11/2023 04:07:44 PM

Document Has Been Signed on 02/11/2023 04:07 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 - NAPA		FACILITY NUMBER:	197610133
ADMINISTRATOR:	IBRAHIM, MOSHOOD		FACILITY TYPE:	735
ADDRESS:	16214 NAPA ST		TELEPHONE:	(909) 483-2505
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	02/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Dorcas Baget		TIME COMPLETED:	04:10 PM

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual Required visit to this facility. LPA's temperature taken upon entry. The administrator was contacted and authorized staff to sign.

LPA conducted a tour at 2:25 pm of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

There are two living room areas. One living near front door attached to dining area and 2^nd living room with office combination. The dining and living room areas observed to have adequate furnishings, sufficient lighting and observed to be clean with adequate seating for residents.

The kitchen food supply was observed and sufficient for the four (4) residents. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats. The kitchen was observed to be sanitary. There is an additional refrigerator and deep freezer with food replenishment in the garage.

The medication cart is stored in dining area and was observed to be locked and inaccessible. The sharps are locked in kitchen cabinet near fridge in a locked box and observed to be inaccessible. There are three (3) first aid kits stored in kitchen under bar cabinet observed to be stocked.

There are four (4) bedrooms in the home designated for residents’ use. All bedrooms were properly furnished and had sufficient lighting. There are two (2) bathrooms in home for residents’ use. Each bathroom has posted “wash your hands” signs and were clean, properly supplied and had functional fixtures. The water temperature for resident bathrooms as follows: Bathroom #1 at 125.0 Fahrenheit and bathroom #2 bathroom at 127 than to 125.0 degrees Fahrenheit and waterlog notes 118.0 on morning shift. Staff notes water fluctuates throughout day and will ensure water will be checked on evening shift.

(Cont. to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

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 - NAPA	FACILITY NUMBER: 197610133
	VISIT DATE: 02/11/2023

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(Cont. from 809)

The garage is locked and only accessible from the outside. The laundry room is located in the garage. Washer and dryer observed to be in good repair. The toxins are stored and locked in cabinets above laundry equipment and observed to be inaccessible to residents. Water, canned goods, incontinent supplies, and PPEs stored in garage in a large wooden cabinet. There are also four (4) two-person Ready America Emergency kits stored in garage.

Smoke alarms and carbon monoxide detectors were present and function properly. There are two (2) fire extinguishers: one (1) attached to kitchen wall near sink and one (1) in garage both was observed to charged.

The backyard has a covered porch area, including a patio table, umbrella, and chairs and a covered swing both observed with adequate seating.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

LIC809 (FAS) - (06/04)

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