197610137-3-30-2023-31-AS-TSMH-CQEU2T-20230330151229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610137
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:12:42 PM

Document Has Been Signed on 03/30/2023 03:12 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 - OSBORNE		FACILITY NUMBER:	197610137
ADMINISTRATOR:	IBRAHIM, MOSHOOD		FACILITY TYPE:	735
ADDRESS:	15952 OSBORNE ST		TELEPHONE:	(818) 893-1234
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Adeleye Sotimehin		TIME COMPLETED:	03:20 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 10:05 am, Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by the administrator and disclosed the purpose of the visit. LPA conducted a tour of the physical plant at 10:45 am 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 livingroom, Kitchen, and 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 fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in a lock box on counter next to refrigerator. The resident medications are stored in locked medication cart in the living room and was observed to be inaccessible to residents. The first aid kit is readily available and stored in cabinet area next to bathroom and observed to be fully stocked. There are two (2) fire extinguishers: One (1) in Livingroom attached to wall and one (1) in the laundry room. Both fire extinguishers observed to be charged. Laundry room is located near main entry door. The appliances observed to be functional. Toxins stored in locked bathroom cabinet was observed to be locked and inaccessible to residents. The facility has a total of four (4) bedrooms for residents and two (2) bathrooms for residents use. (Cont to 809 C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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 - OSBORNE	FACILITY NUMBER: 197610137
	VISIT DATE: 03/30/2023

NARRATIVE

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( Cont from 809)
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 sufficient 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 120.8 and 124.6 degrees Fahrenheit.

Garage: Used to store equipment, staff refrigerator and emergency water and excess food.

The backyard has the following: (1) umbrella covered patio table with sufficient seating for the residents, a covered patio swing, and an uncovered patio table and chairs. Covered 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 12:15 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. Six (6) random staff files also reviewed. Staff files had the appropriate training documentation. Yet 3 out of 6 staff files reviewed had expired first aid/ CPR training.

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: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/30/2023 03:12 PM - It Cannot Be Edited

Created By: Tihesha Smith On 03/30/2023 at 02:47 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 - OSBORNE	FACILITY NUMBER: 197610137
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

89965(k)(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 in 3 out of 6 staff records have expired First aid/CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will ensure staff have the required training and will submit proof of current first aid/CPR for all 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: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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