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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603506
Report Date: 06/19/2023
Date Signed: 06/19/2023 12:43:18 PM

Document Has Been Signed on 06/19/2023 12:43 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:
06/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Ademola Salau - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Ademola Salau, Administrator, Josanne Lambert/Direct Support Professional (DSP) and Divette Bias/Program Supervisor and explained the purpose of the visit. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory, of which (2) may be non ambulatory. All clients residing at this facility receive case management services provided by Harbor Regional Center.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility does have COVID-19 signage still posted in the facility. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Surety Bond Insurance (Atlantic Specialty Insurance Company) is valid and in effect. Fire Drill was conducted on 5/22/2023 and Earthquake drill was conducted on 4/18/2023. Outdoor space/backyard was inspected and has a shaded area and sitting area. LPA observed one (1) broken bicycle and the Administrator stated that it will be removed and thrown away to keep the backyard free of obstruction.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms and (2) full bathrooms, a living room/activity area, office area, kitchen, dining area, backyard, and detached garage. Currently, there are three (3) clients living in the facility. Facility is Level 4. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space.The window screen in bedroom #4 was broken with holes and detached from the window. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Detached garage is being used as exercise/activity area for the clients. Additional PPE supplies are also stored in the detached garage. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a storage room where the laundry was located and inaccessible to clients. There are (2) fire extinguishers observed to be fully charged and was last serviced on 2/21/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 114.6 deg F in the kitchen, 118.2 deg F in bathroom #1 and 118.3 deg F in bathroom #2.

*****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 - PENNSYLVANIA
FACILITY NUMBER: 198603506
VISIT DATE: 06/19/2023
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Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 07/28/2024. Administrator has a valid HIV/AIDS training proof at the time of visit.
Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. None of the clients have personal cell phones and (2) out of (3) clients have computers/laptop. LPA conducted (3) client interviews.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C3. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Functional Assessment, Needs & Services Plan, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas and kept in locked storage room outside. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C3 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: According to the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Pursuant to Title 22, deficiency was cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted, and a copy of this report was provided to Ademola Salau, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2023 12:43 PM - It Cannot Be Edited


Created By: Bennette Pena On 06/19/2023 at 12:27 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 - PENNSYLVANIA
FACILITY NUMBER: 198603506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Admnistrator did not comply with the section cited above in which the window screen in bedroom #4 was broken with holes and detached from the window which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator will replace the broken window screen and submit a photo of the fixed and installed window screen in bedroom #4 to CCL/LPA by POC due date.
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: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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