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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002830
Report Date: 05/11/2022
Date Signed: 05/11/2022 01:26:29 PM

Document Has Been Signed on 05/11/2022 01:26 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:REM CALIFORNIA, LLC - SAN JUANFACILITY NUMBER:
345002830
ADMINISTRATOR:DOVE-MOSLEY, TAUKOSHIUAFACILITY TYPE:
735
ADDRESS:3831 SAN JUAN AVENUETELEPHONE:
(916) 550-0668
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 4CENSUS: 2DATE:
05/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Taukoshiua Dove-Mosley, Administrator and Rose Tannenbaum, Program SupervisorTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived for an unannounced pre-licensing inspection for change in ownership. LPA met with Taukoshiua Dove-Mosley, Administrator and Rose Tannenbaum, Program Supervisor, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. The facility is a Level 4 home, vendorized by Alta California Regional Center. LPA observed two (2) clients at the facility at the time of the inspection and (2) clients were currently attending their day program. The facility is currently licensed for (4) clients.

LPA, Administrator and Program Supervisor toured the interior/exterior of the facility, including (4) private client bedrooms, (2) client bathrooms, (1) staff bathroom, kitchen, common area. There is a separate office area off the garage. LPA observed all areas toured to be clean, safe and in good repair and not pose a health and safety risk or personal rights violation. Inside temperature was 77* F. Fire extinguisher last serviced 3/1/2022. LPA observed locked toxins, medications and sharps and sufficient 2+day perishable/7+day non-perishable food. First aid kits on site. Smoke/monoxide alarms in working order and fire drills are conducted monthly. LPA observed games/crafts and sufficient PPE supplies and sanitizer. Hot water in the kitchen measured 116*F. LPA observed resident behavioral binders and reviewed P&I funds and records for (1) client. Discussed current vaccination status of clients and staff and visitor protocols in place. Temperatures being taken daily for clients and staff. Emergency Disaster plan was posted/updated on 3/4/22. Administrator Certificate # 6062840735 (pending receipt) associated to the facility. There are (2) outside gates accessible to the front part of facility. Facility to post additional Covid posters in the restrooms and common areas. LPA to email Covid posters.

Comp III was completed during today's inspection. LPA observed the facility to be in substantial compliance.

Pre-Licensing is complete and facility has no deficiencies.

Exit interview with Program Supervisor. Copy of report left at facility.


SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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