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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603511
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:16:25 AM

Document Has Been Signed on 03/04/2022 11:16 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 - PARK STREETFACILITY NUMBER:
198603511
ADMINISTRATOR:MURRAY, MARSHAFACILITY TYPE:
735
ADDRESS:9559 PARK STREETTELEPHONE:
(310) 935-2811
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 1DATE:
03/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Marsha MurrayTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kruz Long conducted an announced visit to the facility for the purpose of a pre-licensing evaluation.

An application was received on 8/02/21, for Initial License #198603511 Adult Resident Facility to serve ages 18 to 59.

The facility is a single story house located in a residential area which consist of a living room, kitchen, dining area, 3 bedrooms, family room, office, laundry room, 1 1/2 bathrooms and 1 attached garage. There is a large, covered patio area. The client bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, driveway, step and patios are free of obstructions. Front, back and side areas are free of hazards. Bedrooms have all the required furniture such as beds, chairs, dressers, drawers, night stands and overhead lighting. Bathrooms have working toilets, wash basins, stand up shower. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review in the office. Fire Extinguishers are located in the family room and hallway mounted to the wall. Telephone system is a land line located in office. Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked kitchen cupboard. Food supply adequately stored in kitchen cabinets. Dishwasher in kitchen properly installed and functioning. Smoke Detectors and Carbon monoxide detector are operational. Stove burners, oven, microwave, washer, and dryer working. Toxins are locked and stored under the kitchen sink cabinet. Water temperature tested at 117.4 degrees F in the half bathroom. A first aid kit has been inspected and consist the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen cabinet available for staff use but inaccessible to clients. Applicant will be handling cash resources of clients. Cash resources will be locked and stored in the office with P & I Ledger, accessible to designated staff. The facility has board games, books, and other recreational materials for the client's use. There are no Pool/Jacuzzi & Pets on the premises. Fire Clearance was approved on 02/09/22. Continue to LIC809C.....
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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 - PARK STREET
FACILITY NUMBER: 198603511
VISIT DATE: 03/04/2022
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Component III: Waved: Licensee is currently operating under License #198601897 of the same category.

During the pre-licensing inspection, LPA 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 furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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