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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603511
Report Date: 01/09/2025
Date Signed: 01/09/2025 10:18:06 AM

Document Has Been Signed on 01/09/2025 10:18 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REM CALIFORNIA, LLC - PARK STREETFACILITY NUMBER:
198603511
ADMINISTRATOR/
DIRECTOR:		MURRAY, MARSHAFACILITY TYPE:
735
ADDRESS:9559 PARK STREETTELEPHONE:
(562) 263-6036
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 1DATE:
01/09/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Angela Panes - LVN TIME VISIT/
INSPECTION COMPLETED:
10:18 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 12/24/2024. LPA met with Angela Panes - LVN and explained the purpose for todays visit

On 12/15/2024 C1 was hospitalized for pneumonia, on 12/18/24 C1 was placed on comfort measures while in the hospital where they expired on 12/24/2024.

The Department received a copy of the Death Report on 12/24/24 along with the following copies from C1's file: Individual Service Plan dated 10/22/24, Face Sheet, Needs and Service Plan dated 10/21/24, Physician Report dated 5/22/24, and Medication Administration Records from Oct-Nov-Dec 2024.

During todays visit LPA toured C1s room and interviewed LVN Angela Panes.

No concerns, obstructions, or anything out of the ordinary was witnessed during the visit.

LPA has requested facility to obtain and provide Licensing with C1's Death Certificate upon receipt.

No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to Angela Panes - LVN.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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