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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320232
Report Date: 05/08/2023
Date Signed: 05/08/2023 02:36:24 PM

Document Has Been Signed on 05/08/2023 02:36 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA, LLC - E 213THFACILITY NUMBER:
198320232
ADMINISTRATOR:PAGE, LATORIFACILITY TYPE:
735
ADDRESS:1356 E 213TH STTELEPHONE:
(562) 912-7710
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 3DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Latori Page & Nickie SouthallTIME COMPLETED:
12:37 PM
NARRATIVE
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On 05/08/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the program director Latori Page and program supervisor Nickie Southall. LPA explained the purpose of the visit. The facility is licensed for (4) ambulatory clients of which (2) may be non-ambulatory. Currently, the home has (3) clients. They are consumers are Harbor Regional Center clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) clients' rooms, two (2) common bathrooms, a staff office, a living area, a dining area, a kitchen, a den, and an outside patio area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational. The water temperature measured 108.9 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. A working landline telephone was available and operable. An inspection audit of client #1-#3 (C1-C3) service records and staff #1-#5 (S1-S5) personnel file were performed.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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 - E 213TH
FACILITY NUMBER: 198320232
VISIT DATE: 05/08/2023
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

DEFICIENCIES:
LPA identified staff # 3 (S3) did not have a criminal clearance background and had been working at the facility for several months and did not have a LIC 508 on file. Staff #4 (S4) was not associated with the facility and did not have criminal clearance transfer LIC 9182 on file. LPA identified client #1 (C1) is over the age of 60 and did not have an approved Age Exemption approved by Community Care Licensing (cCLD) on file.

Deficiencies cited and Immediate Civil Penalties issues.

An exit interview conducted with Latori Page and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/08/2023 02:36 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 05/08/2023 at 12:02 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - E 213TH
FACILITY NUMBER: 198320232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(A)(f)(1)
80019 (f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility...(1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility failed to associate staff #4 (S4) and did not have a criminal clearance transfer in Guardian. No record of LIC 9172. This violation which poses/posed an immedidate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 80091 regulations and will comply. The administrator shall associate all staff in Guardian prior to employment and must have a criminal clearance background. Proof of correction must be sent by due date: 05/09/23 by via fax 323-981-1781.

This violation was corrected during the visit and was associated on Guardian effective 05/08/23.
Type A
Section Cited
CCR
80019(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Baed on observed and audit of staff records, Staff #3 (S3) is a direct care staff that has been employed at the facility since 12/2022 for months with no record of a criminal background clearance. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 80091 regulations and will comply. The administrator shall obtain a criminal clearance background prior to employment and must have a criminal clearance. Proof of correction must be sent by due date: 05/09/23 by via fax 323-981-1781.

This violation was cleared during the visit when the individual was removed from employment on 05/08/23.
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/08/2023 02:36 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 05/08/2023 at 12:08 PM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - E 213TH
FACILITY NUMBER: 198320232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)(1-5)
85068.4 Acceptance and Retention Limitations (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file: 1) Completed Functional Capabilities Assessment, required by Section 80069.2...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, interview and record review, Client #1 (C1)is over 60 years old, The facility does not have approved age exception for client on file from CCLD. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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The Licensee/Administrator shall review the Title 22 Section 85068.4 regulations and comply. The administrator shall send a request for age exceptions for clients 60 years of age and over by the POC due date: 05/22/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
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