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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603506
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:35:46 PM

Document Has Been Signed on 03/29/2022 01:35 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA, LLC - PENNSYLVANIAFACILITY NUMBER:
198603506
ADMINISTRATOR:SALAU, ADEMOLAFACILITY TYPE:
735
ADDRESS:11343 PENNSYLVANIA AVETELEPHONE:
(562) 529-2524
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 4DATE:
03/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ademola SalauTIME COMPLETED:
02:00 PM
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Licensing Program Analyst(LPA) Nicol Wesley conducted a pre-licensing inspection and met with Administrator Ademola Salau. The facility will be licensed as an Adult Residential facility to serve 4 ambulatory consumers of with two can be non ambulatory within the age of 18-59 years. There are currently 4 consumers in care. The facility phone number is 562 529 2524.

LPA toured the facility and observed the following: Front yard, Garage, Dining area, Living room, 4 bedrooms, 2 bathrooms, office are, Kitchen, laundry room with locked cabinets, back yard and detached garage. Hot water was tested and the temperature measured at 118.4 degrees F. Medications, medication records with manual will be centrally stored in a locked kitchen cabinet. Toxins, detergents, and sharps, are stored in a locked cabinet underneath the kitchen sink and in the locked storage room. Linen, towels, resident's personal kits, and PPE supplies, were observed in the cabinets in hallway #1. The P&I funds are located in a locked file drawer in the office area. The smoke detectors/carbon monoxide detectors were tested and are operable. The alarm system is hardwired, 2 fully charged fire extinguishers(1 in kitchen, 1 in hallway). LPA observed an adequate supply of perishable and non perishable food items.

Component III Orientation with Applicant designee is waived as the applicant designee has completed it in the past. LPA observed all the required postings as mandated including infection control/PPE station. Administrator Certificate Ademola Salau #6032345735 expires on 07/28/2022.

Continued on LIC 809C.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REM CALIFORNIA, LLC - PENNSYLVANIA
FACILITY NUMBER: 198603506
VISIT DATE: 03/29/2022
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The following items are needed prior to licensure:
  • Repair the chipped paint/stucco on dining room wall, consumer bedroom walls(1-4).
  • Repair the floor threshold strip between the kitchen and dining room.
  • Facility kitchen cabinets to have a dirt build up and the kitchen floors to contain a build up of dirt(bottom of the refrigerator, stove and cabinet near the refrigerator).
  • Cleaning/rust removal of the kitchen appliances are required(refrigerator and dishwasher).
  • Thoroughly clean, dust, and remove cobb webs from the ceilings in the entire facility including consumer bedrooms and the bathrooms.
  • Please purchase additional sets of bath towels, hand towels and wash cloths for consumers(cannot be shared).
  • Non-slip mat for the bathroom shower.
  • CAB(Centralized Application Bureau) to finalize application.

The Administrator Ademola Salau will contact LPA Wesley when the items have been corrected/obtained. If the applicant requires additional questions/concerns regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

Exit interview was conducted with Applicant designee/Administrator Ademola Salau along with a copy of this facility report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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