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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320155
Report Date: 04/22/2023
Date Signed: 04/27/2023 09:05:43 AM

Document Has Been Signed on 04/27/2023 09:05 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA LLC - BALTICFACILITY NUMBER:
198320155
ADMINISTRATOR:WHITLEY JOHNFACILITY TYPE:
735
ADDRESS:2800 BALTIC AVETELEPHONE:
(562) 424-9555
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY: 3CENSUS: 3DATE:
04/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:56 AM
MET WITH:VERRETTA BOATNERTIME COMPLETED:
12:45 PM
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On 04/22/23 Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit using the new Care Inspection Tool. LPA met with Director Verretta Boatner, the purpose of today’s visit was explained.

There are currently (3) Regional Center consumers in placement. All (3) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and a detached garage.

LPA and Director toured the entire facility inside and out. All rooms were inspected. Bedrooms 1 - 3 are occupied by clients and contain the mandated furniture. The (3) bathrooms are clean an operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Facility files were current along with medications. The hot water temperature is at 113.5F degrees Fahrenheit. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins items are inaccessible to clients. Two (2) fire extinguishers are fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and hazards. The facility is in good repair.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA LLC - BALTIC
FACILITY NUMBER: 198320155
VISIT DATE: 04/22/2023
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 During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the staff bathroom and additional sanitation supplies in a locked cabinet located in the office. LPA observed staff and clients wearing masks, an isolation room and required postings throughout the facility. The administrator advised LPA that sanitizer is administered to client with the supervision of staff, but sanitizers are not kept in their rooms for safety reasons. The facility has an approved Mitigation plan. Visitors are logged and checked. The client’s temperatures are checked and logged 3x a day. The Facility fees and Liability Insurance are current.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observed any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Verretta boatner the Facility Director and a copy of the report was provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2023
LIC809 (FAS) - (06/04)
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