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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610133
Report Date: 03/28/2025
Date Signed: 03/28/2025 03:44:40 PM

Document Has Been Signed on 03/28/2025 03:44 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.ASC, 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: 4DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Gboyega AkinbolaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 9:00 a.m. on 03/28/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

The facility was last visited on 03/10/2025 for a complaint visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for four (04) nonambulatory residents.

LPA observed a maintained front yard and an unlocked front gate. A screening station at the front contained surgical masks, sanitizer, and a visitor log. Postings at the front and near the office area included COVID precautions, facility license, confidential complaints contacts, emergency disaster plan, personal rights, emergency contacts, and the facility sketch. Also posted were activity calendars and a weekly menu in the kitchen.

Walls, floors, windows, screens, and blinds were clean and in good repair. Around 9:30 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. The living rooms contained televisions, music equipment, reading material, exercise equipment, board games, puzzles, and furniture in good repair. The office area contained locked medications in the med cart and locked confidential files.

LPA called the house telephone at 9:50 a.m. The phone was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. Appliances were in good condition. Cleaning solutions were locked under the sink. Sharps were locked above the counter. A first aid kit was locked below the counter. The stove surface and hood were clean.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - NAPA
FACILITY NUMBER: 197610133
VISIT DATE: 03/28/2025
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All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. Auditory alarms were turned on and functioning. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition, a maintained backyard, and exercise equipment. At 9:55 a.m. smoke and carbon monoxide detectors were tested and operational. The hallway fire door closed when tested. At approximately 10:05 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/16/2024 with a tag attached.

The facility has four (04) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has two (02) bathrooms. Both bathrooms contained liquid soap, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. The bathroom designated for three (03) out of the four (04) clients did not have toilet paper or paper towels. Around 10:10 a.m., Staff #1 (S1) explained that clients do not use the paper supplies appropriately, so staff assist clients with their toileting needs and supply paper supplies as needed. At approximately 10:30 a.m. LPA measured the water temperature in the main bathroom to be 109.2 degrees Fahrenheit.

The garage contained a washing machine and dryer in working order, an extra refrigerator and freezer, and extra supplies. Detergents and cleaning supplies were locked near the appliances.

At approximately 11:00 a.m. LPA reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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