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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610134
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:15:06 PM

Document Has Been Signed on 03/10/2022 12:15 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 - DONNAFACILITY NUMBER:
197610134
ADMINISTRATOR:TURYASIIMWA, ASSUMPTAHFACILITY TYPE:
735
ADDRESS:9512 DONNA AVETELEPHONE:
(818) 998-3161
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Elizabeth Freeman TIME COMPLETED:
12:25 PM
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At 11:10 A.M Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility mentioned above to conduct an unannounced annual inspection. LPA Martinez was greeted by staff Abimbola Adeyemi and later met with Administrator Elizabeth Freeman. A physical tour was conducted at 11:20 a.m. and the following was observed: Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPAs’ temperature and was asked to sign-in and fill out visitor’s questionnaire. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps, cleaning supplies and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:36 a.m. and appear to be functional. Fire extinguisher has a service date of 11/18/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 74.0 F. Clients Rooms: Facility has four (4) bedrooms all designated for client use. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the clients. Towels are not shared. Trash cans in client’s bedrooms had tight fitting lids. All rooms have adequate lighting. Bathrooms: LPA observed all bathrooms to have grab bars and non-skid mats. At 11:44 a.m. the hot water was tested and measured at 109.5 F. There are three (3) bathrooms in the facility in which two (2) are designated for clients use. All trash cans located in the bathrooms had tight fitting lids. Garage: There is an attached garage and is being used for additional storage. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water

Exit interview conducted/report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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