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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320232
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:50:25 PM

Document Has Been Signed on 03/27/2024 03:50 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Martel Plonick & Robyn HoodTIME COMPLETED:
02:33 PM
NARRATIVE
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On 03/27/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Program Director Martel Plotnick and Program Supervisor Robyn Hood. 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 109.1 degrees F. A comfortable temperature of 70 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: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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Document Has Been Signed on 03/27/2024 03:50 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/27/2024 at 12:56 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The facility failed to conduct quarterly fire drills. The last drill conducted was on 10/09/23. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Licensee will adhere to H&S Regulations and conduct a fire drill by 04/10/24. Proof of correction must be sent by due date 04/10/24 by fax at 424-544-1075 attention Ernand Dabuet.
Type B
Section Cited
CCR
80066(a)(c)
80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified staff #4 & #5 did not have personnel files for CCLD to audit during inspeciton visit. This violaiton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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LIcensee will adhere to Title 22 80066 and ensure that all employees must maintain a personnel file at the facility for CCLD to audit. Proof of correction must be sent by fax to 424-544-1075 attention Ernand Dabuet by 04/10/24.
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: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REM CALIFORNIA, LLC - E 213TH
FACILITY NUMBER: 198320232
VISIT DATE: 03/27/2024
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.

The facility has a $454.00 annual fees due by 04/14/24. LPA left an invoice with the Program Director.

DEFICIENCIES:
Staff #4 and #5 (S4 & S5) was not associated with the facility and did not have criminal clearance transfer LIC 9182 on file. During file review, it revealed that facility has not been consistent in conducting fire drills quarterly with the last drill conducted on 10/09/23. Personnel files for staff #4 and #5 (S4 & S5) were not available for CCLD to audit during inspection visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 6), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

Deficiencies cited and Immediate Civil Penalties issues.



An exit interview conducted with Martel Plotnick and a copy of the report was provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/27/2024 03:50 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/27/2024 at 01:20 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(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 licensee did not comply with the section cited above. LPA identified during aduit of records, staff #4 & #5 did not have criminal clearance transfer request with a LIC 9182. Both staff have been working at the facilty over 14 days. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee failed to associate staff #4 (S4) & staff #5 (S5) and did not have a criminal clearance transfer in Guardian. No record of LIC 9182. The licensee will ensure to submit a LIC 9182 to CCLD or associate the staff in Guardian by due date: 03/28/24. Proof of correction must be sent to LPA Dabuet at ernand.dabuet@dss.ca. gov
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: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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