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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320155
Report Date: 02/26/2025
Date Signed: 02/26/2025 12:02:07 PM

Document Has Been Signed on 02/26/2025 12:02 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 - BALTICFACILITY NUMBER:
198320155
ADMINISTRATOR/
DIRECTOR:		WHITLEY JOHNFACILITY TYPE:
735
ADDRESS:2800 BALTIC AVETELEPHONE:
(562) 424-9555
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 3CENSUS: 3DATE:
02/26/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Stacey Cheat, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 02/26/2025 at 9:15 am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced continuation annual visit using the CARE Inspection Tool. LPA met with the Stacey Cheat, Program Supervisor and the purpose of today’s visit was explained. The facility has a annual fee of $454 due on 03/30/2025. LPA provide pin# 043645 to the facility with the option to make online payment for the annual fees.

Between the hours of 9:30am - 11:30am, LPA conducted a records review of (5) staff records, and (1) clients Personal & Incidental (P & I). The Personal Incidental is complete and two (2) of five (5) staff files are complete.

LPA observed the following not in compliance:
On 02/26/2025, LPA conducted a file review of staff files and did not observe 2 out 5 staff did not have LIC 503 Health Screening and TB test results.

Deficiencies Cited Under California Code of Regulations Title 22, Division 6, Chapter 1.



Exit interview conducted with Stacey Cheat, Program Supervisor and a copy of the report and the appeal rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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Document Has Been Signed on 02/26/2025 12:02 PM - It Cannot Be Edited


Created By: Zina Brown On 02/26/2025 at 11:49 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REM CALIFORNIA LLC - BALTIC
FACILITY NUMBER: 198320155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited abovefor two (2) out of five (5) staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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The program supervisor will submit proof health screening for Staff #4 and Staff #5 by POC due date via email at zina.brown@dss.ca.gov
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited abovefor two (2) out of five (5) staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
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The program supervisor will submit proof tuberculosis (TB) test results for Staff #4 and Staff #5 by POC due date via email at zina.brown@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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