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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881066
Report Date: 04/05/2022
Date Signed: 04/05/2022 10:44:23 AM

Document Has Been Signed on 04/05/2022 10:44 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REM CALIFORNIA, LLC - SKYLANDFACILITY NUMBER:
331881066
ADMINISTRATOR:FLORENCE, TAMARAFACILITY TYPE:
735
ADDRESS:24795 SKYLAND DRTELEPHONE:
(951) 601-3444
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Tamara Florence TIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA)’s, Janira Arreola and David Cuevas made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA's were greeted and granted entry by staff, Tamara Florence who was informed of the purpose of the visit. At the time of visit there was 3 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases. LPA did not observe any pools or bodies of water within the premises. LPA's were informed that no weapons or ammunition is maintained at the home. Annuals fees are current.

During today's visit, LPA’s toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA's observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms (3 restrooms.)

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed and provided to facility administrator, Tamara Florence.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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