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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701094
Report Date: 12/31/2024
Date Signed: 12/31/2024 02:21:03 PM

Document Has Been Signed on 12/31/2024 02:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REM CALIFORNIA, LLC - NORTHFACILITY NUMBER:
342701094
ADMINISTRATOR/
DIRECTOR:		DEANNA WATSONFACILITY TYPE:
735
ADDRESS:4530 NORTH AVENUETELEPHONE:
(916) 515-8096
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 4CENSUS: 1DATE:
12/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Tommesha KilgoreTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived unannounced at the facility to conduct a case management visit. LPAs Pang Lee and Williams talked with Deanna Peabody on the phone and explained the purpose of the visit. Peabody gave permission for Tommesha Kilgore to sign the report.

In an interview with the administrator for REM California LLC North, Deanna Peabody said that Alta California Regional Center (ACRC) refused transport and Peabody use the facility van to transport R! and R2. Peabody said, S1 was training S2. Peabody said S1 and S2 drove R1 to the Adult Day Program. Peabody said that S2 was driving. S1 came back to the facility and then went home but did not show up for work the next day. Peabody asked S1 why S1 did not show up for work and S1 said S1 was upset because S2 was texting and driving. Peabody S1 said that S2 also grabbed R1 by both shoulders and shook R1 awake to tell R1 to get off the bus.

In an interview, S1 said that S2 put one hand on each shoulder and shook resident awake when they arrived at the Adult Day Program. S1 said that S2 was texting while driving and S1 said S1 saw a phone in S2’s hand but S1 heard typing (clicking noises).
Based on interviews the above allegations are SUBSTANTIATED, which means that the allegations are valid because the preponderance of the evidence standard has been met.
This facility is hereby cited per 22 CCR Section 80072(a)(1). An exit interview was conducted with Tommesha Kilgore. A copy of this report and appeal rights were left with Kilgore.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Holly Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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Document Has Been Signed on 12/31/2024 02:21 PM - It Cannot Be Edited


Created By: Holly Williams On 12/31/2024 at 02:10 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REM CALIFORNIA, LLC - NORTH
FACILITY NUMBER: 342701094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/01/2025
Section Cited
CCR
80072(A)(1)

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80072(a) :
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:

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Licensee agrees to conduct training on personnel rights and send the sign in sheet to LPA Williams. Licensee agrees to send a plan of training and date it will be finished by POC due date. Holly.williams@dss.ca.gov
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Based on record review, and interview the resident was handled roughly which poses an immediate health, safety and/or personnel rights risk.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Holly Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
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