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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881066
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:09:28 AM

Document Has Been Signed on 09/16/2024 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REM CALIFORNIA, LLC - SKYLANDFACILITY NUMBER:
331881066
ADMINISTRATOR/
DIRECTOR:		FLORENCE, TAMARAFACILITY TYPE:
735
ADDRESS:24795 SKYLAND DRTELEPHONE:
(951) 601-3444
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Program Supervisor, Brandyn HamiltonTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Janira Arreola and Armando Perez conducted an unannounced visit for a case management visit. LPAs met with Program Supervisor, Brandyn Hamilton, who was informed of the purpose of the visit.

The visit was in response to an incident report that was received on 8/8/2024 for incident occurring on 5/13/2024. The incident report indicated Staff #1 (S1) had called Client #1 (C1) an inappropriate name while feeding the resident. LPA conducted interviews, observations and records review during the visit. LPA conducted a file review for incident report and was shown proof for email sent to the department on 5/14/2024.

Due to insufficient information available at this time, the incident require(s) further investigation. Possible additional visits and/or phone calls may be necessary to determine investigatory findings. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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