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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701094
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:47:29 AM

Document Has Been Signed on 12/08/2022 11:47 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:REM CALIFORNIA, LLC - NORTHFACILITY NUMBER:
342701094
ADMINISTRATOR:SMITH, BOYDFACILITY TYPE:
735
ADDRESS:4530 NORTH AVENUETELEPHONE:
(916) 515-8096
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 4CENSUS: 4DATE:
12/08/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Zobee Miller/Boyd Smith TIME COMPLETED:
12:00 PM
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On December 8, 2022, an informal office meeting was held via Microsoft Teams to discuss compliance with the regulations/or specific incidents that has occurred within the last 12 months. Present in the meeting is Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Pang Lee, Licensing Program Analyst Avelina Martinez, and REM California, LLC-North Susanna Magana, Boyd Smith, Zobee Miller. The informal conference process was explained during this meeting.

Issues discussed during the meeting were:
  • Staffing Ratio
  • Medication
  • Personal Rights
  • Appoint a Certified Administrator
  • Employee Exclusion

The facility has stated they will do the following to achieve continued and substantial compliance:
  • Training on employee incident reporting.
  • Oversight on medication supply and implement weekly medication refill policy.
  • Management will conduct unannounced facility visit to provide oversight of the facility.
  • Implement staffing coverage policy.
  • Acquisitionist Recruiter- will continue to provide oversight on staffing ratios, and continue to hire staff.



Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: REM CALIFORNIA, LLC - NORTH
FACILITY NUMBER: 342701094
VISIT DATE: 12/08/2022
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Community Care Licensing Department (CCLD) will do the following:
  • Increase Monitoring
  • Technical Support Program (TSP) referral

The licensee was advised failure to follow agreed plan could result in a Non-Compliance Conference.

No deficiencies were cited during today's meeting. An exit interview was conducted with facility representative Susana Magana via telephone, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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