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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881066
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:16:21 PM

Document Has Been Signed on 03/15/2024 12:16 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
RIVERSIDE ASC, 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:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Brandyn Hamilton - SupervisorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Supervisor Brandyn Hamilton and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin observed the facility to be a comfortable temperature of 74 degrees and that the hot water in the bathroom faucets measured at 105.6, 106.5, and 105.4 degrees. LPA Colvin did not observe any obstructions to emergency exits or hallways/walkways. LPA Colvin observed staff testing the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives and dangerous chemicals were in two cabinets in the kitchen, which had the capability to be locked but were not locked at the time of the inspection. Deficiency cited. LPA Colvin toured the grounds of the facility and observed all exits to be unlocked and clear from obstruction. LPA Colvin additionally observed several broken and discarded pieces of furniture around the perimeter of the building, including in the backyard and on the left side of the building. Deficiency cited.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 4 ambulatory residents, two of which may be non-ambulatory.
Food Services: LPA Colvin observed the facility to have the required amount of perishable and non-perishable food. LPA Colvin observed the kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware were present for residents’ use.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: REM CALIFORNIA, LLC - SKYLAND
FACILITY NUMBER: 331881066
VISIT DATE: 03/15/2024
NARRATIVE
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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin observed that the acting Administrator for the facility, Amber Cloud, does not have a current Administrator Certificate, though her application for a renewal is pending. Amber Cloud informed LPA Colvin over telephone that another staff member with a current Administrator Certificate is also assisting in the interim, though they are looking to hire a replacement Administrator. LPA Colvin confirmed staff have training to perform their required duties, including current CPR/First Aid Certification. LPA Colvin observed that 1 of 2 staff present during today's inspection (S1) is not currently associated to the facility but does have a criminal record exemption on file. Review of S1's file reveals that S1 has been employed at the facility since 2023. Deficiency cited. When a facility has staff present who do not have a criminal background clearance or exemption transferred to the facility, a civil penalty of $100 a day for every day the person is at the facility is assessed. LPA Colvin will be assessing a $500 civil penalty ($100 a day for 5 days), which is the maximum that can be assessed unless the violation is repeated.

Resident Records: LPA Colvin reviewed the files for all 4 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin was unable to interview residents today as they were all out in the community during the inspection. LPA Colvin additionally reviewed resident medications and did not observe any concerns during today's inspection.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a closet and is inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions, though they do retain resident(s) with Restricted Health Condition(s) and have the required Care Plans and training on file.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and conducts regular Emergency Disaster drills.

An exit interview was conducted with Supervisor Brandyn Hamilton and Administrator Amber Cloud (via telephone), and a copy of this report, LIC9102, LIC809D, LIC421BG, LIC9098 Proof of Corrections, and appeal rights were provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/15/2024 12:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/15/2024 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REM CALIFORNIA, LLC - SKYLAND
FACILITY NUMBER: 331881066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one area of facility (backyard), which poses safety or personal rights risk to persons in care. LPA Colvin observed broken and discarded furniture in the backyard and left side of the building.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee agrees to remove broken/discarded furniture. Licensee to provide LPA Colvin with photographic proof of removal. Due by Plan of Correction date of 4/5/24.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 drawers storing dangerous items in the facility, which poses/posed a potential health and safety risk to persons in care. LPA Colvin observed two drawers in the kitchen which contained chemicals and sharps such as knives to be unlocked.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee agrees to conduct in-service training with all staff on importance of ensuring dangerous items are locked and inacessible at all times. Licensee to provide LPA Colvin with sign-in sheet for in-service training. Due by Plan of Correction date of 4/5/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/15/2024 12:16 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/15/2024 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REM CALIFORNIA, LLC - SKYLAND
FACILITY NUMBER: 331881066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(4)
Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 of 2 staff members present at the facility (S1), which poses an immediate safety risk to persons in care. LPA Colvin observed that S2 has a criminal record expemption, but that it has not been transferred to the facility.
POC Due Date: 03/16/2024
Plan of Correction
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Licensee agrees to submit a request fro S1's exemption to be transferred to the facility. Licensee may self-certify to LPA Colvin once complete. Plan of Correction due by 3/16/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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