197610136-4-11-2023-31-AS-TSMH-CQSVYG-20230411165107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610136
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:51:15 PM

Document Has Been Signed on 04/11/2023 04:51 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 - NORTH HILLS		FACILITY NUMBER:	197610136
ADMINISTRATOR:	TURYASIIMWA, ASSUMPTAH		FACILITY TYPE:	735
ADDRESS:	16312 TUPPER STREET		TELEPHONE:	(818) 830-5275
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Ridwan Olatoyinbo		TIME COMPLETED:	04:53 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 1:05 pm, Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by staff and disclosed the purpose of the visit. LPA conducted a tour of the physical plant at 1:15 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs of residents. These included the kitchen, and living room/dining area combination. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in a lock box in locked lower kitchen cabinet. The resident medications are stored in locked medication cart in the kitchen and was observed to be inaccessible to residents. The first aid kit is stored in medication cart and stored and observed to be fully stocked. There are two (2) fire extinguishers: One (1) near front entrance attached to wall and one (1) in the kitchen attached to wall. Both fire extinguishers observed to be charged. Laundry room is located in the kitchen. The appliances observed to be functional. Toxins under kitchen sink and observed to be locked and inaccessible to residents. (Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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 - NORTH HILLS	FACILITY NUMBER: 197610136
	VISIT DATE: 04/11/2023

NARRATIVE

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(Cont from 809)

The facility has a total of four (4) bedrooms for residents and two (2) bathrooms for
residents use. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hallway closet.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 124.8 and 124.5 degrees Fahrenheit.

Garage: Used to store equipment, back up refrigerator, emergency water, PPEs, and Ready America emergency food packs. The backyard has the following: (1) covered patio, with table with sufficient seating for the residents and a pool table. Patio furniture observed to be in good repair.

Smoke detectors and Carbon Monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There is no body of water in the facility. There were no immediate
health and safety hazard observed during the day of inspection.

At approximately 2:15 pm, LPA reviewed files for the four (4) residing residents. Resident files included medical assessments, physician orders for medications and centrally stored medication logs (facility moving to electronic files to include MAR). Medications are given as prescribed. Five (5) random staff files also reviewed. Four (4) staff files had the appropriate training's to include DSP1 and 2/Crisis management and First aid/CPR. One staff file had expired first aid/CPR and Administrator certificate expired.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2023 04:51 PM - It Cannot Be Edited

Created By: Tihesha Smith On 04/11/2023 at 04:18 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 - NORTH HILLS	FACILITY NUMBER: 197610136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(12)(B)1

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review) the licensee did not comply with the section cited above due to administrator certificate is expired which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2023
	Plan of Correction
1 2 3 4	Administrator will provide current copy of administrator license

Type B

Section Cited

CCR

80075(f)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on(record review the licensee did not comply with the section cited above as staff had expired first aid/CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2023
	Plan of Correction
1 2 3 4	Administrator will send proof of current first aid/CPR certificate for facility staff.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Naira Margaryan

LICENSING EVALUATOR NAME:

Tihesha Smith

LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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