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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603511
Report Date: 03/03/2023
Date Signed: 03/03/2023 04:08:43 PM

Document Has Been Signed on 03/03/2023 04:08 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 - PARK STREETFACILITY NUMBER:
198603511
ADMINISTRATOR:MURRAY, MARSHAFACILITY TYPE:
735
ADDRESS:9559 PARK STREETTELEPHONE:
(562) 263-6036
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 2DATE:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Marsha Murray, AdministratorTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with LVN/DSP staff Eloisa Filio and explained the purpose of the visit. Administrator Marsha Murray arrived shortly after. There are three (3) non-ambulatory developmentally disabled clients in the home. Two (2) clients are ages 18-59 and one (1) client is 72 years old. The facility is licensed as a Specialized Residential Adult Residential Facility (ARF) vendored 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 and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. Each client room is designated as a COVID-19 isolation room if needed. An Infection Control Plan and COVID-19 Mitigation Plan was reviewed.


Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for three (3) non-ambulatory clients. of which 1 may be bedridden. It consists of 4 client bedrooms, living room, dining room, family room, kitchen, 2 bathrooms, backyard patio area, and an attached garage.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has three (3) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients.
  • Oxygen tanks were observed to be secured on stands. Mechanical lifts in client bedrooms and client bathrooms were observed to be operational. All client rooms have Hoyer lifts.
  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
  • A discarded bath bed was observed in the back patio. A deficiency was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 03/03/2023
NARRATIVE
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Operational Requirements:
  • The copy of the Program Design & Plan of Operation on file was the former licensee copy. Administrator obtained from corporate office a copy of this licensee's Program Design & Plan of Operation during the visit.
  • Fire clearance was approved on 2/9/2022 by LA County Fire Department for three (3) non-ambulatory clients.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies to meet the persons with special needs were observed.
  • Surety bond and Certificate of Liability Insurance were received.

Staffing:
  • A total of 16 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 4/30/2023.
  • Five (5) staff files were reviewed for criminal background clearance and training. Staff (S1) is not associated to the facility. Association ended 4/4/2022. Administrator was advised to complete association via Guardian. A deficiency was cited with civil penalty.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information:
  • Physician orders for postural supports and devices were reviewed in client files.

Client Records/Incident Reports:
  • Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, medication records, Restricted Health Care Plans, and P & I money were reviewed.

Food Service:
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
  • Two (2) clients are fed via G-Tube. Physician orders for modified diets are on file. One (1) month supply of food was observed. One (1) client has mechanical soft diet.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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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: 03/03/2023
NARRATIVE
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Facility has six (6) LVNs that are trained to administer injections, suppository assistance, and G-Tube cleaning and medication administration.
  • One (1) client require PRN oxygen administration. One (1) client is administered PRN nebulizer.
  • Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care.
  • Medications are given according to Physician directions.

Incident Medical and Dental:
  • All clients have Restricted Health Care Plan and Needs and Services Plan on file.
  • LVNs administer client suppositories. LVN license training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation, storage and preservation of medications, operation of manual assist devices,
  • An emergency drill has not been conducted since 11/16/2020. The facility shall conduct a drill at least quarterly for each shift.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview conducted with LVN Eloisa Filio. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2023 04:08 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/03/2023 at 03:16 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 - PARK STREET
FACILITY NUMBER: 198603511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that a bath bed was observed discarded in the backyard patio; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Administrator agreed to submit picture proof that the discarded bath bed in the backyard has been removed.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that a disaster drill has not been conducted since 11/16/2020; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Administrator agreed to submit a copy of the disaster drill training log with staff signatures by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2023 04:08 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/03/2023 at 03:25 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 - PARK STREET
FACILITY NUMBER: 198603511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1) is not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2023
Plan of Correction
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Administrator agreed to submit proof that staff (S1) was associated to the facility.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023


LIC809 (FAS) - (06/04)
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