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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881066
Report Date: 12/02/2022
Date Signed: 12/02/2022 11:09:02 AM

Document Has Been Signed on 12/02/2022 11:09 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: 3DATE:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christine Ross, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Administrator Christine Ross. The visit was in response to the death of Resident #1 (R1), who passed away on December 1, 2022.

During LPA's visit, LPA reviewed R1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's reports, resident appraisal, appraisal needs and service plan, progress notes, and medication records (MAR) for November 1, 2022 - November 17, 2022. LPA also requested a copy of R1s death certificate when it is made available.

During today's visit no deficiencies were cited in regard to this incident.

An exit interview was conducted, and a copy of this report was provided along with a copy of the LIC811 (confidential names list).
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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