198320232-3-30-2022-11-AS-GJON-CCZPZT-20220330114604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320232
Report Date: 03/30/2022
Date Signed: 03/30/2022 11:46:39 AM

Document Has Been Signed on 03/30/2022 11:46 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	REM CALIFORNIA, LLC - E 213TH		FACILITY NUMBER:	198320232
ADMINISTRATOR:	PAGE, LATORI		FACILITY TYPE:	735
ADDRESS:	1356 E 213TH ST		TELEPHONE:	(562) 912-7710
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY: 4		CENSUS:	DATE:	03/30/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	LATORI PAGE		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	03/30/22, Licensing Program Analysts (LPA) Gail Johnson conducted an announced visit to this home. LPA was greeted by applicant Latori Page and explained the purpose of today’s pre-licensing inspection visit. An application was submitted and received by CCLD on 08/02/21. In the initial license application for a Residential Facility for Adults, ages ranging from 18-59 years old. The applicant requested for a capacity of four (4) individuals, of which two (2) may be ambulatory and two (2) non-ambulatory. Structure: The home includes four (4) bedrooms, two (2) bathrooms, and is a one-story home (in a residential neighborhood). The home is a gray color structure that includes a living, dining, kitchen, office, and laundry area. The living area included sofas and a table. The kitchen has laminate countertops with a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. The outdoor area has a table, four (4) chairs and an umbrella for shade. Bedrooms Clients: The facility had four (4) private bedrooms for clients. There are two (2) bedrooms for ambulatory clients and (2) two bedrooms for non-ambulatory clients. All rooms include (1) a full-size bed, one (1) chair, one (1) nightstand, one (1) table lamp. All bedrooms are equipped with ceiling fan lights. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Bedrooms Staff / Bathrooms No bedrooms designated for staff. The home has two (2) bathrooms. Two (2) bathrooms are located in the same hallway that leads to all client bedrooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats. Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 - E 213TH	FACILITY NUMBER: 198320232
	VISIT DATE: 03/30/2022

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in bedroom closets.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There is one (1) fire extinguisher located in the dining area, mounted on the wall and fully charged. A cordless telephone (connected to the line) is available in the kitchen and living room area.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are in a locked cabinet. Food supply is stored in kitchen cabinets and consists of can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors are located throughout the interior space. Smoke detectors and carbon monoxide detectors are interconnected in all hallways and common areas. Smoke detectors are in all four (4) bedrooms.

Toxins / Water Temperature / Appliances
All toxins are locked/stored inside the kitchen hall closet. The water temperature is 118.6 degrees Fahrenheit throughout the kitchen and bathrooms. Stove burners, oven, microwave, washer, and dryer are all working. The kitchen counters also had small appliances which include a toaster, blender, and coffee maker. There is one (1) refrigerator in the home. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. The residence is equipped with central air and heat.

Medications, First-Aid Kit & Book:
A first aid kit is stored in a cabinet that has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications will be stored in a cabinet locked in the kitchen and inaccessible to clients.

Evaluation Report Continues

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 - E 213TH	FACILITY NUMBER: 198320232
	VISIT DATE: 03/30/2022

NARRATIVE

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Clients & Staff Files:
The applicant is handling the cash resources of clients (as necessary) and will be in a locked cash box inside the office area. Records of staff and clients will be in a shelving area in the office.

Reading Material, Games, Equipment & Activities:
The facility has board games, books, magazines, arts/crafts, puzzles, pottery decorating and other activities for the client's use all stored in a corner of the kitchen across from the dining area. All activities are for client use align with the plan of operation.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the fenced area.

Evaluation Report Continues

Fire clearance:
A Fire Clearance inspection was conducted on 02/16/22 with approval for a capacity for two (2) ambulatory, two (2) for non-ambulatory.

Component III:
LPA Johnson conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPA observed no corrections during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the applicant, Latori Page. LPA Gail Johnson will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

>END OF REPORT<

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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