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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603507
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:20:55 PM

Document Has Been Signed on 04/14/2022 12:20 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 - NECTARFACILITY NUMBER:
198603507
ADMINISTRATOR:DIAZ, JESSICAFACILITY TYPE:
735
ADDRESS:20832 NECTAR AVETELEPHONE:
(562) 809-1950
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY: 4CENSUS: 4DATE:
04/14/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica Diaz - AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Mora conducted an announced Pre-Licensing visit. LPA met with Administrator Jessica Diaz and explained the reason for the visit. An application was submitted to Community Care Licensing Department (CCLD) for a change in ownership of an Adult Residential Facility to serve 4 ambulatory clients in the age range of 18 through 59.

A tour of the single-story facility included: living room, kitchen, dining area, 4 client bedrooms, 2 bathrooms, attached garage, front yard, and backyard.

LPA Mora conducted the tour with Jessica Diaz and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and in the refrigerators located in the garage. Sharps and First Aid kit are kept locked in a kitchen closet. The First Aid kit was fully stocked with all required items including a current manual. Chemical solutions are kept locked under the kitchen's sink. Each bedroom has clean extra linen. Dining and living room have sufficient lighting and sitting area. Medications are centrally stored in a locked kitchen cabinet. All bedrooms have all required furniture, lighting, and bedding. Both bathrooms were observed with shower mats. Water temperature was tested at 112.7 degrees F, which is within the required 105-120 degrees F. Fire extinguishers were observed in the hallway and kitchen, and fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. Carbon monoxides were observed in the kitchen and hallway and were operable during the visit. The front yard and backyard are clean, and there is a shaded sitting area in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. LPA reviewed all 4 of the clients’ medications and files. Medications are documented properly and given as prescribed. Client files are complete and updated. LPA reviewed 2 staff files. Staff files are complete and updated. LPA observed administrator certificate for Jessica Diaz 6039585735 with an expiration date of 05/15/2022.
(CONTINUED TO LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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 - NECTAR
FACILITY NUMBER: 198603507
VISIT DATE: 04/14/2022
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No outstanding or pending items were observed by LPA requiring additional pre-licensing visits. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation.

Exit interview conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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