197610133-4-15-2024-31-AS-TSMH-D4CSKQ-20240415135707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610133
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:57:27 PM

Document Has Been Signed on 04/15/2024 01:57 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/ DIRECTOR:	IBRAHIM, MOSHOOD		FACILITY TYPE:	735
ADDRESS:	16214 NAPA ST		TELEPHONE:	(818) 892-2800
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	04/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:35 PM
MET WITH:	Gboyega Akinbola		TIME VISIT/ INSPECTION COMPLETED:	02:05 PM

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced 1-year visit to this facility. LPA

Smith was greeted by staff and the administrator was present at the facility.

LPA conducted a tour at 12:45 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 family room with 2 office area combinations. 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 hot water temperature for resident bathrooms as follows: Bathroom #1 at 109.5 Fahrenheit and bathroom #2 bathroom at 112.5 degrees.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - NAPA	FACILITY NUMBER: 197610133
	VISIT DATE: 04/15/2024

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(Cont from 809)
appliances. Toxins 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.

Client recycling discussed-will be removed/non issue.

No hazards observed at time of visit.

Due to time constraints record review will be completed at a later time.

Exit interview conducted/Copy of report given

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SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC809 (FAS) - (06/04)

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