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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002830
Report Date: 05/24/2023
Date Signed: 05/24/2023 02:15:23 PM

Document Has Been Signed on 05/24/2023 02:15 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 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:
05/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rose Tannenbaum , AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with Rose Tannenbaum, Administrator, to conduct a case management visit. The purpose of today’s visit is to follow-up on information obtained regarding the facility’s license during an annual inspection conducted on 5/17/23.

The facility has an approved license for 4 ambulatory clients. The facility currently has 2 residents (R1 & R2) that utilize assistance devices for mobility. The facility did not contact CCL regarding the need to change their fire clearance status to include non-ambulatory clients. CCL will be in contact with Sacramento Metro Fire Department to conduct a fire inspection at the facility to obtain approval for non-ambulatory clients.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, Division 6. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

Exit interview conducted. Report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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 05/24/2023 02:15 PM - It Cannot Be Edited


Created By: Angela Hood On 05/24/2023 at 01:54 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: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2023
Section Cited
CCR
80020(b)(2)

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80020 Fire Clearance (b)The applicant shall notify the licensing agency if the facility plans to admit any of the following categories of clients so that an appropriate fire clearance, approved by the city or county, fire department, the district providing fire protection services, or the State Fire Marshal, can be obtained prior to the acceptance of such clients: (2) Persons who are nonambulatory
This requirement was not met as evidenced by:
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LIcensee will provide LPA with LIC200 for change in fire clearance by the POC due date of 5/25/23.
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Based on records review, the licensee did not ensure to contact CCL regarding the need to change their fire clearance status to include non-ambulatory clients, which poses an immediate health, safety, and personal rights risk to the residents in care.
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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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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