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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320234
Report Date: 03/17/2023
Date Signed: 03/17/2023 03:47:05 PM

Document Has Been Signed on 03/17/2023 03:47 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 - 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:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Latori Page - AdministratorTIME COMPLETED:
04:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit to review the physical plant, and review client and staff records. LPA was met by administrator Latori Page (A1) and the purpose of today’s visit was explained.

There are currently (3) Harbor Regional Center (HRC) clients in placement. All (3) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. A1 and LPA made a complete tour of the facility which consisted of the following: Kitchen, Living room, three (3) bedrooms, two (2) bathrooms, dining area, laundry room (located in hallway closet toward bedroom three (3)), detached garage, outdoor shaded area with indoor/outdoor activity areas. Bedrooms #1-3 are designated as the client's bedrooms. Each bedroom has one client per room.

LPA and A1 toured the physical plant. There are no bodies of water or firearms/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were clean and operational, but outside Title 22 regulations. The water temperature measured 134.4 F in bathroom number two ( #2). A comfortable temperature is maintained in the facility at 69.9 F. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguishers were charged, last charged on 3/22/22, smoke detectors and Carbon Monoxide were operable with the latest fire drill on 2/20/23.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (located in common areas and restrooms). LPA observed staff were wearing face coverings, an isolation room and required postings were posted throughout the facility.
See LIC809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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 4
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 - MARCELLUS
FACILITY NUMBER: 198320234
VISIT DATE: 03/17/2023
NARRATIVE
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LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PINs) for any updates relating to community care guidance.

During today’s visit there were three (3) deficiencies observed, see LIC809-D.

Exit interview held. A copy of the report was provided to Latori Page, Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/17/2023 03:47 PM - It Cannot Be Edited


Created By: Mario Leon On 03/17/2023 at 03:19 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 - MARCELLUS
FACILITY NUMBER: 198320234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in showing a broken outer pane of window in bath number two (#2) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Administrator Latori Page (A1) and LPA Leon have agreed that A1 will submit photo evidence of proper maintenance of the window located in bathroom number two (#2) on, or prior to, the the POC due date which has been marked as 3/31/23. Evidence shall be submitted via email at MARIO.LEON@DSS.CA.GOV .
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's measurement, the licensee did not comply with the section cited above in having current water temperatuer at 134.4 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2023
Plan of Correction
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Administrator Latori Page (A1) and LPA Leon have agreed that A1 will submit video evidence of water temperature within Title 22 regulations (105 F- 120 F) on, or prior to, the the POC due date which has been marked as 3/20/23. Evidence shall be submitted via email at MARIO.LEON@DSS.CA.GOV
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/17/2023 03:47 PM - It Cannot Be Edited


Created By: Mario Leon On 03/17/2023 at 03:19 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 - MARCELLUS
FACILITY NUMBER: 198320234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in having both LIC501 and LIC503 pages for staff member present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
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Administrator Latori Page (A1) and LPA Leon have agreed that A1 will submit photocopy evidence of proper LIC files (LIC501, LIC503) for staff member Ophelia Lawrence on, or prior to, the the POC due date which has been marked as 3/27/23. Evidence shall be submitted via email at MARIO.LEON@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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023


LIC809 (FAS) - (06/04)
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