198320235-2-28-2022-11-AS-SCAS-CC46J3-20220228195029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320235
Report Date: 02/25/2022
Date Signed: 02/28/2022 07:50:58 PM

Document Has Been Signed on 02/28/2022 07:50 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	REM CALIFORNIA, LLC - OCANA		FACILITY NUMBER:	198320235
ADMINISTRATOR:	MURRAY, MARSHA		FACILITY TYPE:	735
ADDRESS:	3839 OCANA AVE.		TELEPHONE:	(562) 354-6589
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY: 3		CENSUS: 2	DATE:	02/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Marsha Murray		TIME COMPLETED:	02:15 PM

NARRATIVE

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On 02/25/22 at 12:35pm, Licensing Program Analyst LPA/ Susan Campos conducted an announced visit to the facility for purpose of a pre-licensing evaluation.

An application for new ownership was submitted to CCLD on 8/2/21, for an initial license application for an Adult Residential Facility to serve Developmentally Disable Adults, ages ranging from 18 to 59 years. The applicant requested for a capacity for three (3) individuals of which two may be non-ambulatory and (1) bedridden. Currently, the facility has 3 clients living in the facility. LPA was greeted and accompanied by Administrator Marsha Murray during the inspection.

The home is vendorized through the Harbor Regional Center.

Structure:

The home consists of 3 client bedrooms, 2 full bathrooms, living room, kitchen, dining room, family/activity room, and laundry room, including an unattached garage used for storage.

Facility has (3) bedrooms, (2) bathroom, it is single story house with an unattached garage used for storage. The facility is a tan stucco structure/ white trim with a floor plan which includes: living room, dining room, kitchen and family/ activity room and garage. Ramp location on side of home for entry and exit from the residential home. The interior has lighting throughout. The living area had no fireplace. The living area also included (1) sofa/ (2) Accent chairs and a side table/ Staff office area. The kitchen has granite counter tops with refrigerator, stove/ microwave, and on counter toaster, coffee machine and blender. Den/ family room has large screen television, with (2) sofa, cabinets, and recreational games, coffee table. Two storage closets in the hallway. Garage is used for storage of supplies and food. Emergency food and water is located in the garage, and a facility transportation van. During the visit, LPA noticed passageways, walkways steps and

Report Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - OCANA	FACILITY NUMBER: 198320235
	VISIT DATE: 02/25/2022

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patios are free from obstructions. LPA observed a covered back yard deck with patio cover table and two chairs.

Bedrooms Clients:

The facility had three (3) bedrooms. All client bedrooms #1-#3 have one (1) chair, one (1) full size bed, one (1) night stand, one (1) table lamp, and (1) dresser, complies with the requirement of 8 cubic feet of space.

All rooms also had closets for ample storage, and also are equipped with ceiling lights.

Appliances:

Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which included: toaster, coffee maker, and blender. There is one (1) refrigerator in the home. The refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at zero degrees Fahrenheit. The residence is equipped with central AC/heating.

Toxins:

All toxins are locked/stored under kitchen cabinet sink, and Laundry room cabinet.

Water Temperature:

Bathroom hot water tested at 107.5 degrees Fahrenheit for bathroom 1, and 108.9 degrees Fahrenheit for bathroom #2.

Medications, First-Aid Kit & Book:

A first aid kit stored in the kitchen has been inspected which has the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual locked and inaccessible to clients. Client's medications will be stored in the den cabinet locked and inaccessible to clients.

Clients & Staff Files:

Applicant will be handling cash resources for clients. Cash resources will be locked and stored with P & I Ledger, in den room closet, accessible to designated staff only. Files for clients and staff will be stored and

Continued on LIC 809C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - OCANA	FACILITY NUMBER: 198320235
	VISIT DATE: 02/25/2022

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locked in den room closet.

Reading Material, Games, Equipment & Materials:

The facility has board games, books, magazines and other recreational materials for the client's use all stored in the den room cabinet, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:

There are no pets, jacuzzi or pool in the fenced area.

Fire clearance:

Fire Clearance on 1/25/22, approval for a capacity for three (3) clients, Bedroom #1 bedridden client and Bedroom 2 and 3 non-ambulatory client. The House has a pull bell alarm station, (2) fire extinguisher, and (4) smoke detectors that were checked and found to be operable.

Component III:

LPA / Campos conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been furnished to Administrator, Marsha Murray. Accordingly, LPA/ Campos will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC809 (FAS) - (06/04)

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