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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320155
Report Date: 08/30/2022
Date Signed: 08/31/2022 02:31:18 PM

Document Has Been Signed on 08/31/2022 02:31 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:
08/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:ADMINISTRATOR WHITLEY JOHNTIME COMPLETED:
01:32 PM
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On 08/30/2022 around 09:00am Licensing Program Analyst (LPA) Jose Calderon initiated an unannounced Case Management visit - Other to provide Technical Assistance to the above said facility Rem California LLC-Baltic. Today’s visit was conducted face to face with administrator S1.

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 S1.

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 R1. On 06/23/2022 LPA Calderon interviewed Administrator S1 who states that she was advised of the allegation of assault on 05/26/2022 by S2 against R1. S1 states S1 was advised by S2 that no assault happened. S1 spoke to W1 who stated that no assault had happened. On 06/23/2022 LPA Calderon interviewed R1 who did not remember what had happened and stated no assault had happened. On 06/23/2022 LPA Calderon reviewed R1 medical records to include behavior frequency log, LPA Calderon noted R1 false allegations, physical aggression, seeks attention. On 08/30/2022 LPA Calderon interviewed S2 who stated R1 had made false allegations against S2 and other staff in the past and assault never happened. S2 states that he spoke to W1 who interviewed S2 and stated no assault had happened.

An exit interview was conducted with administrator S1 and a hard copy was provided via email for signature.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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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