331881066-3-7-2023-18-AS-CNWE-CPPVR9-20230307153935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881066
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:39:41 PM

Document Has Been Signed on 03/07/2023 03:39 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	REM CALIFORNIA, LLC - SKYLAND		FACILITY NUMBER:	331881066
ADMINISTRATOR:	FLORENCE, TAMARA		FACILITY TYPE:	735
ADDRESS:	24795 SKYLAND DR		TELEPHONE:	(951) 601-3444
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY: 4		CENSUS: 3	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Christine Ross, Administrator		TIME COMPLETED:	03:45 PM

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On March 7, 2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Program Supervisor, Jennifer Rambeau who was informed of the purpose of the visit. Jennifer called Administrator, Christine Ross who arrived at the facility shortly after. At the time of visit there was 4 staff and 3 residents present. LPA toured the facility inside and out with Jennifer Rambeau.

Tour included:

Kitchen; LPA toured the kitchen and observed food is stored in a safe and healthful manner. Knives and cleaning solution are adequately secured under the sink. LPA inspected the fire extinguisher located in the kitchen and found it to be in compliance and record to be up to date

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 72 degrees Fahrenheit.

Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPA observed medications were labeled and stored in separate bins inside of a locked closet by the front room and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REM CALIFORNIA, LLC - SKYLAND	FACILITY NUMBER: 331881066
	VISIT DATE: 03/07/2023

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Continued from LIC809

Bathroom; LPA inspected the three #3 hall bathrooms and observed bathrooms to be clean and equipped with grab bar. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 105 degrees Fahrenheit.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage; LPA tour the garage and observed garage to be clean.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gates remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Randomly selected five #5 staff and three #3 residents' files were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expired on 8/4/2022. Christine Ross stated renewal application was sent to CDSS last year but haven’t received the new administrator certificate yet.

Interview; LPA interviewed three #3 staff and three #3 resident.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Christine Ross.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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