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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881066
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:43:05 PM

Document Has Been Signed on 09/26/2024 03:43 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/
DIRECTOR:		FLORENCE, TAMARAFACILITY TYPE:
735
ADDRESS:24795 SKYLAND DRTELEPHONE:
(951) 601-3444
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 4CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Program Supervior, Brandyn HamiltonTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings on investigation done for a case management. LPA met with Program Supervisor, Brandyn Hamilton who was informed of the purpose of the visit. The investigation consisted of conducted interviews, documented observations, and records review.

The regional office received an incident report 5/13/2024. The incident report indicated Staff #1 (S1) had called Client #1 (C1) an inappropriate name while feeding the resident.

LPA conducted (1) staff interview. LPA attempted to contact (2) other staff for interviews who witnessed the incident, however attempts to contact staff were unsuccessful. Staff interviewed revealed S1 had called C1 an inappropriate name, and when the incident was reported to upper management an investigation was conducted. Staff interviewed revealed S1 admitted to calling C1 an inappropriate name and S1 was then terminated. LPA reviewed documents unpaid leave notice for S1 on 5/14/2024, and notice of termination and investigation. S1’s termination was effective 5/22/204, with the conclusion of verbal abuse toward C1. Therefore, the preponderance of the evidence standard has been met.

California Code of Regulations Title 22 is being cited on the attached LIC809-D page. A collaborative plan of correction was created with staff. An exit interview was conducted where this report, LIC809-D page and appeal rights were reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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Document Has Been Signed on 09/26/2024 03:43 PM - It Cannot Be Edited


Created By: Janira Arreola On 09/26/2024 at 03:19 PM
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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
80072(a)(1)

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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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The staff agreed to conduct personal rights training with staff. Documentation to be submitted to LPA by poc due date. Staff agreed to send LPA
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Based on interview and record review, it was found that S1 addressed C1 in an inappropriatly. This poses an immediate health saftey or personal rights risk to clients in care.
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Staff in service for October 16, 2024 and have one of the topic covered be personal rights.

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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:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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