198603508-3-24-2023-28-AS-AGOZ-CQ8RVP-20230324132152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603508
Report Date: 03/24/2023
Date Signed: 03/24/2023 01:22:20 PM

Document Has Been Signed on 03/24/2023 01:22 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 - BELLFLOWER		FACILITY NUMBER:	198603508
ADMINISTRATOR:	MANALASTAS, ALBERTO		FACILITY TYPE:	735
ADDRESS:	6129 BELLFLOWER BLVD		TELEPHONE:	(562) 866-9634
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90713
CAPACITY: 4		CENSUS: 4	DATE:	03/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Martel Plotnick		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Gonzalez met with Administrator Martel Plotnick and explained the purpose for the visit. The facility is licensed to serve four (4) developmentally disabled clients (age 18-59) and is approved for 1 nonambulatory. Currently, there are four (4) clients in placement (all ambulatory), there are no clients who have a restricted health care condition. All clients residing at this facility receive case management services provided by Harbor Regional Center. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Per Facility Administrator all four (4) clients have COVID-19 vaccines including boosters. Per Facility Administrator all staff also have the COVID-19 vaccines including boosters. Facility Administrator is adhering to infection control requirements. Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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 3

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 - BELLFLOWER	FACILITY NUMBER: 198603508
	VISIT DATE: 03/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Operational Requirements: Fire Drills are conducted quarelty, the last fire drill was conducted on 1/2023. Emergency Disaster/ Earthquake Drills are conducted quarterly and the last one was conducted on 1/2023. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: The facility is a single story home located in a residential neighborhood and consists of: four client bedrooms, two bathrooms, staff office, living room, Kitchen, and Dining area. All client rooms were inspected and LPA observed client beds and the bedding for each bed were in good condition, adequate lighting provided, storage for client personal belongings was observed for each client. Walls and floors were in good repair. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to clients. Water temperature properly measured at 114 F*. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Martel Plotnick expires on 1/26/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting.

Client Rights-Information: Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services to all clients which clients utilize through their personal cell phone.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights.

Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 - BELLFLOWER	FACILITY NUMBER: 198603508
	VISIT DATE: 03/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Food Service: The facility has sufficient food supplies of 2-day perishable and a week of 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 (locked in the laundry area). 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 (bubble packs). LPA reviewed medication for C1 through C4. The facility uses the ECP - Extended Care Professional (online charting system) to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly.

Incidental Medical Services: Per Facility Administrator, there are no clients at this home with incidental medical services nor any client that has a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster Plan readily accessible.

Emergency Intervention : Not-Applicable.

No deficiencies noted. Exit interview and a copy of this report was provided to Administrator Martel Plotnick.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3