<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610136
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:00:38 PM

Document Has Been Signed on 05/09/2024 03:00 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 HILLSFACILITY NUMBER:
197610136
ADMINISTRATOR/
DIRECTOR:		TURYASIIMWA, ASSUMPTAHFACILITY TYPE:
735
ADDRESS:16312 TUPPER STREETTELEPHONE:
(818) 830-5275
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Ridan OlatoyinboTIME VISIT/
INSPECTION COMPLETED:
03:02 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
Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at 10:20 am. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was present at the facility.

LPA conducted a tour of the physical plant at approximately 10:40 am to ensure there are no health and safety hazards and facility is following 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. There is 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 in cabinet beneath oven. T
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.

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. There are two (2) fire extinguishers: One (1) near bathroom attached to wall and one (1) in the kitchen attached to wall. Both fire extinguishers observed to be charged.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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 3
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: 05/09/2024
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
26
27
28
29
30
31
32
( Cont from 9099)

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 108.1 and 109.9 degrees Fahrenheit.

Garage: Used to store residents bikes, emergency water, and additional refrigerator stocked with milk and foods. The backyard has the following: Screened patio, with table with sufficient seating for the residents and Foos Ball table. Patio furniture observed to be in good repair.

Smoke detectors and Carbon Monoxide detectors 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 11:07 am, LPA reviewed files for five (5) random staff files also reviewed. Five (5) staff files had the appropriate trainings to include DSP and administrator has current administrator license posted. Two staff had expired First aid/CPR and technical advisory to provide current update for one CPI record and bathroom wall. Four (4) resident records have admissions agreements, and Individual Service Plans and or Individual Program plans.

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 given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/09/2024 03:00 PM - It Cannot Be Edited


Created By: Tihesha Smith On 05/09/2024 at 02:51 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: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 in 2of 2 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Provide current first aid/CPR card for identified staff.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3