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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603506
Report Date: 05/22/2023
Date Signed: 05/22/2023 12:51:51 PM

Document Has Been Signed on 05/22/2023 12:51 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 - PENNSYLVANIAFACILITY NUMBER:
198603506
ADMINISTRATOR:SALAU, ADEMOLAFACILITY TYPE:
735
ADDRESS:11343 PENNSYLVANIA AVETELEPHONE:
(562) 529-2524
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 3DATE:
05/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Divette Bias - Direct Support Professional & Program SupervisorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management visit. LPA met with Josanne Lambert/Direct Support Professional and Divette Bias/Direct Support Professional (DSP) & Program Supervisor and explained the reason for the visit.

On 3/01/2023, LPA Pena observed during a complaint visit for complaint #28-AS-20230224160606, that the hot water temperature in bathroom #1 measured below 100 deg F and stayed low even after 11 minutes and 34 seconds, which is not within Title 22 guidelines.

During today's subsequent visit, LPA spoke to the Administrator Ademola Salau by phone - 323-351-0610 at 11:22am and informed him that case management report and deficiency will be issued.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit on 3/01/2023 is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided to Divette Bias, Direct Support Professional & Program Supervisor.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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Document Has Been Signed on 05/22/2023 12:51 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/22/2023 at 11:45 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REM CALIFORNIA, LLC - PENNSYLVANIA
FACILITY NUMBER: 198603506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2023
Section Cited
CCR
80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies..(e) Faucets used by clients for personal care ... shall deliver hot water. (1) Hot water temperature controls shall be maintained.. hot water delivered ..... 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
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During the subsequent visit on 5/22/2023, at 11:42am, LPA tested the hot water temperature in bathroom #1 and now measured at 116.6 deg. F which is within Title 22 Regulations.The deficiency has been cleared during today's visit.
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which during the visit on 3/01/2023, the hot water temperature in bathroom #1 reading stayed below 100 deg F even after 11 minutes and 34 seconds which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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