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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610137
Report Date: 03/18/2024
Date Signed: 03/18/2024 02:01:37 PM

Document Has Been Signed on 03/18/2024 02:01 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 - OSBORNEFACILITY NUMBER:
197610137
ADMINISTRATOR:IBRAHIM, MOSHOODFACILITY TYPE:
735
ADDRESS:15952 OSBORNE STTELEPHONE:
(818) 893-1234
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Gboyega AkinbolaTIME COMPLETED:
02:10 PM
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At 10:40 am, 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 11:00 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 living room, 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 adequate supply of meats and 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 new and 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 and two (2) bathrooms for residents
(Cont to 809 C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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: 03/18/2024
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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 hasthe 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 119.7 and 119.8 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 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 12:50 pm, LPA reviewed files for the four (4) residing residents. Resident files included physician's report, daily notes, Service plans. Five (5) random staff files had the appropriate training documentation and current first and CPR.

Technical advisory for: Three (3) wood fence panels to secure.

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

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2024 02:01 PM - It Cannot Be Edited


Created By: Tihesha Smith On 03/18/2024 at 01:43 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: 03/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation) the licensee did not comply with the section cited above as one bathroom wall at bottom has mildew/need repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
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