331881068-3-14-2023-18-AS-CNWE-CPWPYM-20230314114410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881068
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:44:19 AM

Document Has Been Signed on 03/14/2023 11:44 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	REM CALIFORNIA LLC - BAXTER		FACILITY NUMBER:	331881068
ADMINISTRATOR:	SIBANDE, CAROLINE		FACILITY TYPE:	735
ADDRESS:	13508 BAXTER COURT		TELEPHONE:	(951) 247-4555
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 4		CENSUS: 3	DATE:	03/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Caroline Sibande, Administrator		TIME COMPLETED:	11:50 AM

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On March 14, 2023, Licensing Program Analysts (LPA’s) Chinwe Nwogene and Jacqueline Shaw arrived unannounced at the facility to conduct an annual inspection. LPAs was greeted and granted entry by Caregivers, Nicole Como and Iokapeta Esera who was informed of the purpose of visit. Administrator, Caroline Sibande arrived at the facility shortly after. At the time of visit there was 2 staff and 1 resident present. LPAs toured the facility inside and out with Iokapeta Esera.

Tour included:

Kitchen; LPAs toured the kitchen and observed kitchen to be clean and food stored in a safe and healthful manner. LPAs observed knives and cleaning solutions are adequately stored under the kitchen sink.

Dining and Livingroom; LPAs toured the dinning and Livingroom area. LPAs observed area to be clean and furnitures in good condition. Temperature was 75 degrees Fahrenheit.

Hallway; LPAs toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly.

Medications: LPAs observed medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Bathroom; LPAs toured hall bathroom and observed bathroom 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

Continue on LIC809-C

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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 - BAXTER	FACILITY NUMBER: 331881068
	VISIT DATE: 03/14/2023

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Continued From LIC809

Bedroom; LPAs toured four #4 out of #4 residents bedrooms 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. Resident bedroom #3 and #4 has a shared bathroom. LPAs observed bathroom to be clean and hot water was measured at 108 degrees Fahrenheit. LPAs observed additional linens in residents’ closets.

Laundry room and Garage; LPAs tour the Laundry room and observed Laundry room to be clean, equipped with washing machine and dryer. LPAs observed laundry solutions are adequately secured in a locked cabinet. LPAs toured the garage and observed garage to be clean and not cluttered.

Backyard; LPAs toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate 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. Five #5 staff and three #3 residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 10/23/2024.

Interview; Three #3 staff and one #1 resident was interviewed.

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 Caroline Sibande.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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