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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603505
Report Date: 03/10/2023
Date Signed: 03/10/2023 05:09:39 PM

Document Has Been Signed on 03/10/2023 05:09 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA, LLC - GLENWOODFACILITY NUMBER:
198603505
ADMINISTRATOR:PARRA, DENISEFACILITY TYPE:
735
ADDRESS:2418 GLENWOOD PLACETELEPHONE:
(323) 249-8299
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 4DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Program Supervisor, Lizbeth CortezTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Ana Saavedra, Direct Support Professional/DSP and discussed the purpose of today's visit. LPA Pena spoke to Administrator, Denise Parra on the phone who stated that she will not be able to come to the facility. At 2:13pm, Program Supervisor Lizbeth Cortez arrived and assisted LPA with the inspection. The facility cares for Level 4-I Adult Residential age range 18 through 59, 4 ambulatory only. Facility is serviced by Harbor Regional Center. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff and resident files. This single-story home contains four (4) bedrooms, two (2) full bathrooms, a living room, kitchen, dining area, office area, backyard, and detached garage.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility.
  • Facility maintained a 30-day supply of PPE located in the shed outside and in the garage.
  • The laundry room is clean and has cleaning supplies inaccessible to clients.
  • The kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and are working properly.
  • Cleaning solutions and sharps were locked and inaccessible. However, LPA observed a Lysol cleaner under the bathroom sink, unlocked and accessible to clients.
  • Water temperature was measured in kitchen and bathrooms. Kitchen measured at 115.1 deg F, bathroom #1 measured at 115.3 deg F and bathroom #2 measured at 111.3 which are all within the required 105 - 120 degrees.
  • Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms have the required non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Clients' medications were reviewed to confirm medication is given as prescribed and is documented properly.


***Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA, LLC - GLENWOOD
FACILITY NUMBER: 198603505
VISIT DATE: 03/10/2023
NARRATIVE
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  • Staff wore face masks throughout their shift.
  • The common areas such as living/activity room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The backyard has a shaded area and sitting area. The activity area and backyard has been designated as the visitor area during the COVID-19 pandemic.
  • There are fire extinguishers in the hallway and kitchen and observed to be fully charged and last serviced in March 2022. LPA reminded Program Supervisor Lizbeth Cortez to have the fire extinguishers inspected before March 17, 2023.
  • There are no cameras or bodies of water in the facility.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Client files were reviewed to confirm emergency contact is up to date. Clients have health screenings and or vaccinations.
  • Six (6) staff files were inspected and contained required health screenings, criminal record clearances, and training certificates. However, none of the staff had valid First Aid Certificate on file to prove that they received the training.
  • Administrator certificate is valid and expires 06/27/2024.
  • Surety Bond number 800151293 is valid effective 2/01/2023. Bond is covered by Atlantic Specialty Insurance Company.

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and copy of the report and appeals rights were provided to the Program Supervisor, Lizbeth Cortez.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/10/2023 05:09 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/10/2023 at 04:47 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - GLENWOOD
FACILITY NUMBER: 198603505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not comply with the section cited above in that LPA observed a Lysol cleaner in an unlocked cabinet under the bathroom sink which was accessible to clients which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 03/13/2023
Plan of Correction
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During the visit, Program Supervisor Lizbeth Cortez removed the hazardous material/Lysol cleaner from the cabinet under the bathroom sink.Program Supervisor agreed to re-train the staff members about storing the cleaning solutions in locked cabinets.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/10/2023 05:09 PM - It Cannot Be Edited


Created By: Bennette Pena On 03/10/2023 at 04:47 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - GLENWOOD
FACILITY NUMBER: 198603505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Administrator did not comply with the section cited above in that all (6) staff files reviewed did not have a First Aid certificat to prove that they received the training which posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 03/13/2023
Plan of Correction
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Administrator will ensure that all staff have received the first aid training and keep the certificates on file. Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature be submitted to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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