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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881068
Report Date: 04/14/2022
Date Signed: 04/14/2022 06:00:49 PM

Document Has Been Signed on 04/14/2022 06:00 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 - BAXTERFACILITY NUMBER:
331881068
ADMINISTRATOR:SIBANDE, CAROLINEFACILITY TYPE:
735
ADDRESS:13508 BAXTER COURTTELEPHONE:
(951) 247-4555
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 3DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Administrator Caroline SibandeTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA were greeted and granted entry by administrator, Caroline Sibande, who was informed of the purpose of the visit. At the time of visit there was 4 staff and 3 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA’s toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA'observed Covid-19 postings posted throughout the facility. LPA made a technical advisory note to administrator that hand washing poster be poted in all bathrooms. This was documented on an LIC 9102TA. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer) in all restrooms. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility also has a designated infection control lead and cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed sufficient PPE supplies.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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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 - BAXTER
FACILITY NUMBER: 331881068
VISIT DATE: 04/14/2022
NARRATIVE
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LPA along with administrator noticed the following deficiencies:

· LPA was unable to inspect all of the facility in its entirety. This is a violation of the department's inspection authority.
· Storage room in garage was not located on facility sketch. There was no documentation provide to LPA at time of visit that would provide proof of proper building code guidelines.


An exit interview was conducted, and a copy of this report and appeal rights were reviewed and provided to facility administrator, Caroline Sibande.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/14/2022 06:00 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/14/2022 at 04:50 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 - BAXTER
FACILITY NUMBER: 331881068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80044


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on administrator's inability to grant LPA access to storage room in garage, where client's archived files where being kept, licensee did not comply with the section cited above concerning inspection authority. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Licensee will ensure that all client records are accessible at all times and that all areas of the facility are able to be inspected by the department. Proof of repair of door lock will be submitted to LPA by POC date.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 06:00 PM - It Cannot Be Edited


Created By: Janira Arreola On 04/14/2022 at 05:24 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 - BAXTER
FACILITY NUMBER: 331881068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not informing the department of the construction of a file storage room in the garage. No record was provided at the time of the visit for the building permits for that storage room and the room was not identified on the facility sketch provided. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Licensee will provide LPA an updated facility sketch where garage stroage room is accounted for, and provide proof of building permits for the storage room by POC date.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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