198320155-1-13-2025-11-AS-ZBRN-DCVRAE-20250113115101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320155
Report Date: 01/13/2025
Date Signed: 01/13/2025 04:26:28 PM

Document Has Been Signed on 01/13/2025 04:26 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	REM CALIFORNIA LLC - BALTIC		FACILITY NUMBER:	198320155
ADMINISTRATOR/ DIRECTOR:	WHITLEY JOHN		FACILITY TYPE:	735
ADDRESS:	2800 BALTIC AVE		TELEPHONE:	(562) 424-9555
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90810
CAPACITY: 3		CENSUS: 3	DATE:	01/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:52 AM
MET WITH:	Stacey Cheat, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

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On 01/13/2025 at 8:52am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Stacey Cheat, Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (3) ambulatory adults ages 18 through 59. Currently, the home has (3) clients. The clients are Harbor Regional Center clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility has an annual fee with the balance of $454.00 due on March 17, 2025. LPA provided pin #043645 to the facility with the option to make facility payment online.

The facility is a one story home located in a residential neighborhood. The property consists of the following: 3 client bedrooms, 2 common bathrooms, living room, a laundry room with a washer and dryer, kitchen, dining room, a garage with deep freezer/additional storage and an outdoor shaded area.

LPA conducted a records review of (3) client records, (2) clients Personal & Incidental Records and (3) Client Medication Administration Records. LPA reviewed the facility disaster plan. All client records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. The last emergency drill was conducted on 11/15/2024.

At 9:12am LPA and Stacey Cheat toured the inside and outside of the facility. Client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Kitchen 117.7F, Bathroom #1- 114.4F & Bathroom #2 113.8F).

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REM CALIFORNIA LLC - BALTIC	FACILITY NUMBER: 198320155
	VISIT DATE: 01/13/2025

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

Due to time constraints LPA will continue the annual inspection at a later date. Additional deficiencies will be issued at a later date if necessary.

Exit interview conducted with Stacey Cheat, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

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