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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881068
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:00:33 PM

Document Has Been Signed on 03/22/2024 02:00 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
RIVERSIDE ASC, 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: 4DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caroline Sibande, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Caroline Sibande. The Administrator was notified of the purpose for the visit.

PHYSICAL PLANT: The Licensee is operating the facility within the conditions and limitations specified on the license. Clients appear to be protected against immediate hazards. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to clients in care. A comfortable temperature was being maintained in the home. There was sufficient lighting in all rooms to ensure the comfort and safety of clients. Hot water was tested and observed to be within regulatory requirements. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped clients is available. The smoke and carbon monoxide alarms were tested and found to be operable. The interior and exterior areas of the home were observed to be clean and safe.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean.

RECORD REVIEW: Staff file had required training, including, but not limited to, training to assist clients who are incontinent, first aid training, and emergency and disaster training. Staff present has the required criminal record clearances. An Individual Program Plan (IPP) and Medical Assessment (Physician's Report) was on file for client in care.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - BAXTER
FACILITY NUMBER: 331881068
VISIT DATE: 03/22/2024
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Administrator Sibande has an active Administrator's certificate, which expires on 10/23/2024. An earthquake drill was completed 03/11/2024 and a fire drill completed on 03/05/2024.

MEDICATION: Medication was reviewed for client in care. All medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to clients in care.

Technical violations relating to medication management, tuberculosis testing, and a restricted healthcare plan were observed during the inspection. None of the violations observed posed an immediate health and safety risk to the clients in care.

This report was reviewed with Administrator Sibande and a copy was provided. No deficiencies were cited at time of inspection.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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