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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002830
Report Date: 05/17/2023
Date Signed: 05/31/2023 10:31:20 AM

Document Has Been Signed on 05/31/2023 10:31 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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: 4DATE:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Susana Magana, Regional DirectorTIME COMPLETED:
01:20 PM
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Licensing Program Analysts (LPAs) Angela Hood and Sabrina Calzada arrived at the facility unannounced on 5/17/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with the Regional Director, Susana Magana and explained the purpose of the visit. The facility is a level 4I home that is pproved through Alta California Regional Center. There are currently 2 clients at the home and 2 at day program.

LPAs toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 4 bedrooms and 2 bathrooms for residents, common area, dining room, kitchen, outdoor area, and viewed PPE supplies. The facility has the required 2-day perishable and 7-day non-perishable food supply on hand. The water temperature was 118 degrees. All toxins, knives, and medications are locked and inaccessible to clients in care. LPAs observed that the windows and screens need cleaning. Fire extinguisher was serviced on 3/10/23. The facility has operable smoke alarms and carbon monoxide detector. LPAs and Regional Director completed the infection control domain. LPAs reviewed 2 of 8 staff records and 2 of 4 residents' records. LPA's reviewed P&I funds for (1) resident. The regional center reviewed P&I funds on 5/2/23 and found no errors.

LPAs reviewed the facility vehicle maintenance log and they are doing quarterly maintenance. Facility is conducting fire drills. LPAs obtained a copy of administrator's certificate #6061126735 expires 10/1/23 and Regional Director emailed a copy of the surety bond, LIC500, LIC308, and LIC610D to LPA. The facility is approved for 4 ambulatory clients. However, 2 clients are currently utilizing assistance devices for mobility. LPAs will follow-up with Sacramento Metro Fire.

Per California Code of Regulations Title 22, Division 6, Chapter 8 the following (1) deficiency was observed during today's visit. Citations are issued on the LIC809-D page. Exit interview conducted. A copy of report and appeal rights provided..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 05/31/2023 10:31 AM - It Cannot Be Edited


Created By: Angela Hood On 05/17/2023 at 12:44 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: REM CALIFORNIA, LLC - SAN JUAN
FACILITY NUMBER: 345002830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80087(a)

80087(a) Buildings and Grounds: The faciliy shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees, and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the faciliy windows and screens need cleaning, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2023
Plan of Correction
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Program Director agreed that the faciliy will hire an outside company to clean the windows and screens.

Faciliy will provide a copy of the receipt of cleaning to LPA by the POC due date of 5/31/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Angela Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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