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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320234
Report Date: 02/15/2022
Date Signed: 02/16/2022 11:51:05 AM

Document Has Been Signed on 02/16/2022 11:51 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 - MARCELLUSFACILITY NUMBER:
198320234
ADMINISTRATOR:PAGE, LATORIFACILITY TYPE:
735
ADDRESS:1024 E. MARCELLUS ST.TELEPHONE:
(562) 866-9634
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 3CENSUS: 3DATE:
02/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Latori PageTIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPA) Ana conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on 12/29/2021 for a change of ownership license for an Adult Residential Facility to serve Developmentally Disabled Adults for ages 18-59 years. The requested capacity is for (3) clients, 3 ambulatory and 0 non-ambulatory. Structure: Facility is a three (3) bedroom, one (2) full bathroom, single story house with front yard, detached 2 car garage in the rear of the property. The facility is a red brick structure with rear patio and backyard. Front yard landscape is in good condition. Rear patio is covered with shaded umbrella. Back patio has table, chairs, and washer/dryer area has a utility sink. Signal System: No signal system in facility.

Bedroom Residents: There shall be no more than two clients per bedrooms. bedrooms are designated client private bedrooms properly equipped with regulation guidelines of 1 bed, 1 chair, 1 night stand, and overhead lighting. Presently, 3 bedrooms are occupied by 3 client. Bedroom Staff: No bedrooms will be used for awake staff. Bathrooms: 2 full bathroom located in between the 3 bedrooms of east side of the facility. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in each of the 3 clients bedrooms. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in dining room bulletin board. Facility has a land line telephone located in the kitchen area. 2 Fire extinguisher, one 1A10BC mounted in kitchen wall, and the second 4A60BC in the hallway where bedrooms are located, which are labeled, they are tagged with current annual checks.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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 - MARCELLUS
FACILITY NUMBER: 198320234
VISIT DATE: 02/15/2022
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 Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Dishwasher in kitchen is properly installed and functioning. Smoke Detectors: There are 5 hard wired smoke detectors, and 5 smoke detector is also a carbon monoxide detector located in the hallway bedroom side of facility. Appliances: Stove burners, oven, microwave, and washer/dryer are in working condition. There is one refrigerator in the home. The residence is equipped with central heat and air conditioning. Toxins: Cleaning supplies, and toxins are stored below kitchen sick and laundry area. Water Temperature: Water was tested in bathrooms and kitchen sink within 105-120 degrees Fahrenheit range. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in hallway cabinets with lock. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which are stored with medication in hallway cabinets, available for staff use but inaccessible to clients. Clients & Staff Files: Designated area for files is located in the dining room locked cabinet drawers. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. . Fire Clearance: Fire clearance does not indicate any delayed egress or any locked perimeter. Component III: Conducted at the Pre-Licensing visit.


No corrections to be made.

A visit was conducted and copy of the report has been furnished to the applicant. Accordingly, LPA will submit a copy to the evaluation report to Central Application Unit (CAU) for review. If the applicant has questions regarding the status of the applicant, they have been instructed to communicate with CAU Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2