198603511-4-16-2024-28-AS-AGOZ-D4DVPA-20240416163626

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603511
Report Date: 04/16/2024
Date Signed: 04/16/2024 04:36:50 PM

Document Has Been Signed on 04/16/2024 04:36 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 - PARK STREET		FACILITY NUMBER:	198603511
ADMINISTRATOR:	MURRAY, MARSHA		FACILITY TYPE:	735
ADDRESS:	9559 PARK STREET		TELEPHONE:	(562) 263-6036
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 3		CENSUS: 3	DATE:	04/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Marsha Murray		TIME COMPLETED:	04:30 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 Marsha Murray and explained the purpose for the visit. The facility is licensed to serve (3) non-ambulatory clients ages 18 to 59 years old. Facility is operating within the approved capacity. Currently, there are three (3) clients in placement, and all (3) clients 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: 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. Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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 - PARK STREET	FACILITY NUMBER: 198603511
	VISIT DATE: 04/16/2024

NARRATIVE

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Operational Requirements: Fire Drills are conducted every quarterly, the last fire drill was conducted on 4/12/24. Emergency Disaster/ Earthquake Drills are also conducted every three months and the last one was conducted on 4/12/2024. Facility Administrator is adhering to operational requirements.

Physical Plant & Environment Safety: 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. Bathrooms are clean and operational. All client rooms were checked. All clients beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. 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. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Water temperature properly measured at 116.5F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. A shaded area with chairs is provided for clients in the backyard of the facility

Staffing: 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 (3) staff files. 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. Administrator Certificate is current and expires on 04/30/25.

Refer to LIC 809C for continuation of report

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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 - PARK STREET	FACILITY NUMBER: 198603511
	VISIT DATE: 04/16/2024

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Client Rights-Information: Client personal rights and House Rules are posted. 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, and Restricted Health Care Plans were reviewed.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7 day supply of non-perishable items. The food is properly stored in the refrigerator which is clean and well-maintained. There are three clients that follow a special diet residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1-3. 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. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical Services: 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: The facility has an Emergency Disaster Plan readily accessible. A posted Emergency Disaster Plan LIC 610D containing emergency evacuation, storage and preservation of medications, operation of manual assist devices,

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

No deficiencies/ citations noted. Exit interview and a copy of this report was provided to Administrator Marsha Murray.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC809 (FAS) - (06/04)

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