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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320155
Report Date: 06/23/2022
Date Signed: 06/23/2022 01:29:09 PM

Document Has Been Signed on 06/23/2022 01:29 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA LLC - BALTICFACILITY NUMBER:
198320155
ADMINISTRATOR:GIMM, DONNAFACILITY TYPE:
735
ADDRESS:2800 BALTIC AVETELEPHONE:
(562) 424-9555
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 3CENSUS: 3DATE:
06/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Adrena BoykinsTIME COMPLETED:
01:04 PM
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On 06/23/2022 around 11:00am Licensing Program Analyst (LPA) Jose Calderon initiated an unannounced Case Management visit - Other to provide Technical Assistance to the above said facility. Today’s visit was conducted face to face with administrator Ardrena Boykins.

LPA Calderon tour consisted of a single-story home, all common areas which included but were not limited to; building entrances, reception areas, office, hallways, restrooms, dining room, kitchen, pantry, medication storage and patio area. LPA Calderon also reviewed the facility's entry procedures, body temperature monitoring practices, social distancing practices, protective facial covering practices and disinfection/sanitation practices with Administrator Ardrena Boykins.

The LPA Calderon also requested copies of the facility's records which includes but are not limited to Pre-Placement Appraisal’s, Information's, Reappraisals, Individual Needs and Services Plans, IPP assessments, Behavior assessments, Physicians Reports, Incident Reports, Progress Notes for resident 1. On 06/23/2022 LPA Calderon interviewed Administrator Ardrena Boykins who states that she was advised of the allegation of assault on 05/26/2022 by staff to resident. Administrator states she was advised by S2 that no assault happened.

A telephonic exit interview was conducted with administrator Ardrena Boykins and a hard copy was provided via email for signature.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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