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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603506
Report Date: 06/22/2022
Date Signed: 06/22/2022 11:15:30 AM


Document Has Been Signed on 06/22/2022 11:15 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
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:
06/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ademola Salau- AdministratorTIME COMPLETED:
11:30 AM
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    Licensing Program Analyst (LPA) Valeria Maldonado conducted a subsequent 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 which (2) two may 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.

    During the initial Pre-Licensing visit on 03/29/22, LPA Wesley toured the facility and observed the following items to be corrected:
  • 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 buildup 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 cobwebs 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.


    • During today's visit, LPA Maldonado toured the facility with the administrator and observed the following:
    (Report continued on LIC809C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 06/22/2022
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  • The paint/stucco on dining room wall and consumer bedroom walls #1-#4 were repaired
  • The floor threshold strip between the kitchen and dining room was repaired
  • Facility kitchen cabinets and the kitchen floors have been cleaned and are in good repair
  • Cleaning/rust removal of the kitchen appliances has been completed
  • Cobwebs on the ceiling throughout the entire facility including consumer bedrooms and bathrooms have been cleaned
  • additional sets of bath towels, hand towels and wash cloths for consumers are available
  • Non-slip mats for both bathroom showers have been purchased and placed in showers


    • The following was also observed: Front yard, dining area, living room, 4 bedrooms, 2 bathrooms, office area, kitchen, laundry room with locked cabinets, back yard, and detached garage. Hot water was tested, and the temperature measured at 118.8°F in bathroom#1 and 118.2*F in bathroom#2. Medications and medication records with first aid 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. Linens, towels, resident's personal kits, and PPE supplies were observed in the cabinets in hallway. The P&I funds are in a locked file drawer in the office area. The smoke detectors/carbon monoxide detectors were tested, are interconnected, and operable. 2 fully charged fire extinguishers were observed- (1) in the kitchen and (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.

    During the pre-licensing inspection, LPAs did not observe items which do not comply with applicable laws and regulations.

    An exit interview was conducted, and a copy of this report has been provided to the applicant designee. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant designee has questions regarding the status of the application, they have been instructed to communicate with their assigned CAB Analyst.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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