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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320234
Report Date: 04/19/2024
Date Signed: 04/23/2024 08:39:37 AM

Document Has Been Signed on 04/23/2024 08:39 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:REM CALIFORNIA, LLC - MARCELLUSFACILITY NUMBER:
198320234
ADMINISTRATOR/
DIRECTOR:		PAGE, LATORIFACILITY TYPE:
735
ADDRESS:1024 E. MARCELLUS ST.TELEPHONE:
(562) 866-9634
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 3CENSUS: 2DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Program supervisor Glendy FrancoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 04/19/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Program supervisor Glendy Franco as the purpose of the visit was explained. The facility is licensed to serve 3 ambulatory adults ages 18-59, current census is 2 clients, clients are linked to the Harbor Regional center. Facility fees are up to date.

The facility is a single-story structure located in a residential neighborhood and consists 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. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards. Smoke detectors and Carbon Monoxide were operable

LPA conducted a records review of 1 staff records, 2 client records, LPA was unable to review P&I. A review of 2 medication administration records was conducted, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

Deficiencies cited on 809D.

Client #1 missing Admission agreement, ANS, physicians report, TB test, consent forms, Personal rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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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 - MARCELLUS
FACILITY NUMBER: 198320234
VISIT DATE: 04/19/2024
NARRATIVE
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Client #2 is missing: form, Admission agreement, ANS, physicians report, TB test, consent forms, Personal rights.

Staff file is missing: LIC 501, LIC 503, TB test, employee training.

Exit interview conducted with Program supervisor Glendy Franco, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/23/2024 08:39 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/19/2024 at 11:50 AM
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 - MARCELLUS
FACILITY NUMBER: 198320234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
80023 disaster and mass casualty plan: disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, and record review, the licensee did not comply with the section cited above as there was no documentation detailing when the last fire drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator/staff will conduct drill and provide proof of drill to LPA by POC due date. Documentation for every drill conducted to be maintained at the facility.
Type B
Section Cited
CCR
80066(a)(6-12)
Documentation of the educational background, training and/or experience specified in licensing regulations for the type of facility in which the employee works.
Past experience, including types of employment and former employers.
Duties of the employee.
Termination date if no longer employed by the facility.
A health screening as specified in Section 80065(g).
Tuberculosis test documents as specified in Section 80065(g).
For employees that are required to be fingerprinted pursuant to Section 80019:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), record review)], the licensee did not comply with the section cited above as there was only 1 staff file available for review which was incomplete at the time if visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Administrator/staff to provide completed staff files for all staff listed on LIC 500 including administrator to LPA by POC due date.
LIC 501, LIC 503, TB test, acknowledgement of mandated reporting for adults and elderly.
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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/23/2024 08:39 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 04/19/2024 at 12:07 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 - MARCELLUS
FACILITY NUMBER: 198320234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records

The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as client records are incomplete or outdated upon review which poses/posed a potential health, safety or personal rights risk to persons in care.

Consent forms, admission agreement, physicians report, TB test, LIC 613, SPV,
POC Due Date: 05/03/2024
Plan of Correction
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Administrator/staff to complete/update all client records and provide coppies to LPA by POC due date.
Lizeth.villegas@dss.cs.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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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