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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881068
Report Date: 05/02/2023
Date Signed: 05/02/2023 04:26:16 PM

Document Has Been Signed on 05/02/2023 04:26 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:
05/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Caroline Sibande, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. LPA met with Caroline Sibande. LPA was informed that three (3) residents currently reside at this facility, residents present. There were three (3) staff and Administrator on duty during the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care. Additional information requested was obtained.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Caroline Sibande and a copy of this report will be emailed and a receipt of confirmation will be requested.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2023
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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