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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610134
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:27:43 PM

Document Has Been Signed on 03/27/2023 04:27 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
N LA & CEN COA AC/SC, 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:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ayo Fetuga,Gboyega AkinbolaTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with staff Ayo Fetuga, and advised her of the Annual. The administrator Gboyega Akinbola joined the Annual shortly after.

At approximately 8:30am, with the assistance of the administrator, LPAs took a tour of the physical plant. Required postings were posted. The smoke alarms and sprinkles were observed and interconnected . There is a functional carbon monoxide detector installed in the hallway. The facility is a one story building.There are fire extinguishers located in the hallways and kitchen. The charge date is 11/04/2022.

Kitchen: The kitchen was observed to have functional appliances and fixtures. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored.

Bedrooms: LPAs inspected 4 out of 4 client bedrooms. Bedrooms are for private use. LPA observed each client room to be properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: The facility has has 3 bathrooms. The LPAs took a water temperature from the bathroom sink at 119 degrees F. LPAs observed the bathrooms to be properly supplied and had functional fixtures. No cleaning supplies were observed accessible to the residents in care.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The entrance area was clean, clear and free of any obstruction.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - DONNA
FACILITY NUMBER: 197610134
VISIT DATE: 03/27/2023
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Surrounding Grounds: Entry and exits were free of obstruction. There is a center courtyard area that was also free and clear of any obstruction. The laundry area is located in adjacent to staff bathrooms.

Medications: Centrally stored medications are maintained in the staff work station. Medications were locked in a medication cart. One pharmacy is being utilized for resident use. Refills are either done automatically every 30 days, or ordered by the physician. Medication Records were review for proper documentation. Medication records are maintained both electronically and manually.

Client/Staff Records: At approximately 10:25am, client and staff records were reviewed to insure compliance.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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