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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610134
Report Date: 04/03/2026
Date Signed: 04/03/2026 01:15:01 PM

Document Has Been Signed on 04/03/2026 01:15 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - DONNAFACILITY NUMBER:
197610134
ADMINISTRATOR/
DIRECTOR:		NATASHA OCHAFACILITY TYPE:
735
ADDRESS:9512 DONNA AVETELEPHONE:
(818) 998-3161
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 3DATE:
04/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Abimbola Adeyemi- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff, and explained the reason for the visit. Administrator Abimbola Adeyemi, was contacted and arrived shortly after. At approximately 9:40 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms were tested and appeared functional. There is a functional carbon monoxide detector installed in the kitchen. There are fire extinguishers located in the hallway and kitchen. The service date is 04/17/25.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen.
Bedrooms: There were four (4) bedrooms designated for clients' use. Currently, Room#1 is vacant. All four bedrooms, in use by clients, were private and properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms/ Laundry Area: The facility has two and one half (2 1/2) bathrooms. The two (2) bathrooms are for client use. The half bathroom, located in the laundry area, is reserved for staff. Laundry detergents and toxins were observed to be locked. Water temperature in the bathrooms measured between 105-110 degrees F. Bathrooms designated for clients were properly supplied and had functional fixtures. No cleaning supplies were observed in the bathrooms during inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The gates at both sides of the home were checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation. (Continue on 809C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2026
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - DONNA
FACILITY NUMBER: 197610134
VISIT DATE: 04/03/2026
NARRATIVE
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Staff Workstation/Office: There is a staff office located at the hallway by the kitchen, where staff and client records are kept and locked in a filing cabinet.

Garage: The garage is attached to the building. The garage is used as storage for PPE, emergency kits, food and water. There is also a freezer for additional perishable food items, and a refrigerator for staff use. Entry to the garage from inside the home is located by the kitchen. No cleaning supplies or toxin stored in the garage at the time of the visit.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA observed that C2 did not have an updated Physician Report. In addition, all three clients did not have an updated Needs and Services Plan.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.



Facility file: LPA observed that facility's Emergency Disaster plan is not updated. Administrator agreed to provide an updated plan by 04/17/26.

Medications: Medication and Medication Records were review for proper documentation. Medication records are maintained electronically.

Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit
Cash Resources: LPA with the assistance of the administrator reviewed cash resources for the clients. LPA observed that cash resources and logs are not accurate and are not updated for three out of three clients. Administrator stated that all documents will provided promptly.

Exit interview conducted, citations issued, appeal rights given and copy of this report signed and delivered.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/03/2026 01:15 PM - It Cannot Be Edited


Created By: Mariana Agban On 04/03/2026 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - DONNA
FACILITY NUMBER: 197610134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The facility did not have an updated Needs and Services Plan for three out of three clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Administrator agreed to provide updated Needs and Services Plan for three out of three clients by the POC date.
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. C2 did not have an updated Physician Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Administartor agreed to provide an updated Physician Report for C2 by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2026 01:15 PM - It Cannot Be Edited


Created By: Mariana Agban On 04/03/2026 at 12:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - DONNA
FACILITY NUMBER: 197610134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)


(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The facility did not maintain accurate and updated records of accounts of cash resources for three out of three clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Administrator agreed to provide ccurate and updated records of accounts of cash resources for three out of three clients by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2026


LIC809 (FAS) - (06/04)
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