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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881068
Report Date: 03/27/2026
Date Signed: 03/27/2026 02:58:04 PM

Document Has Been Signed on 03/27/2026 02:58 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/
DIRECTOR:		SIBANDE, CAROLINEFACILITY TYPE:
735
ADDRESS:13508 BAXTER COURTTELEPHONE:
(951) 247-4555
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 4CENSUS: 4DATE:
03/27/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Caroline Sibande/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On March 27, 2026, Licensing Program Analyst (LPA) Robert Campbell arrived unannounced to the facility to conduct a case management visit to address a deficiency observed while investigating a complaint in the facility. LPA met with Caroline Sibande/Administrator, who was informed of the purpose of the visit.

S1 staff arrived at 3pm on 2/03/2026 to begin working, LPA checked the guardian for clearance to work at the facility and found she was not associated cleared with the facility. LPA spoke with the Administrator Caroline Sibande to let the staff leave the facility until she is associated. LPA conducted a review of payroll time in and time out and found the following staff were not on the criminal clearance roster guardian printout for at least three days of work S2 staff, and S3 staff. LPA reviewed documents at the facility on 3/27/2026 to find both S2 & S3 were criminally cleared but not associated to the facility.

Based on the fore mentioned, the facility will be cited and possible civil penalties will be assessed. An exit interview was conducted and a copy of this report, LIC 809-D, LIC 811 Confidential Names and Appeal Rights were reviewed and provided to Caroline Sibande/Administrator. A copy of Title 22, regulation section 80019(e)(3) transfer of criminal record clearance association were also provided for the facility's review.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Robert Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/27/2026 02:58 PM - It Cannot Be Edited


Created By: Robert Campbell On 03/27/2026 at 02:23 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: 03/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2026
Section Cited
CCR
80019(e)(3)

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T22-80019(e)(3) The Dept. shall conduct a criminal record review of all individuals and have authority to approve or deny ... all individuals subject to a criminal record review...prior to working...facility requested transfer of criminal record clearance. Evidenced by the following:
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Licensee will ensure all staff working in the facility are associated prior to working by POC date. The Licensee will contact and be notified of all staff on shift when not present to ensure all staff are associated criminally to the facility by POC date.
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LPAs observed 1 staff during complaint visit on 2/03/2026, and two staff LPA found not associated during payroll record review working estimated three (3) days.
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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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Robert Campbell
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2026


LIC809 (FAS) - (06/04)
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