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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850134
Report Date: 11/22/2021
Date Signed: 11/23/2021 11:23:03 AM

Document Has Been Signed on 11/23/2021 11:23 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - LOMPOCFACILITY NUMBER:
425850134
ADMINISTRATOR:SMITH, RONICAFACILITY TYPE:
775
ADDRESS:1133 NORTH H STREET SUITE FTELEPHONE:
(805) 757-9595
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 45CENSUS: 6DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Ronica Smith, AdministratorTIME COMPLETED:
01:40 PM
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On 11/22/21 at 12:20 PM, Licensing Program Analyst (LPA) Toan Luong arrived at the facility and performed a facility risk assessment with Administrator Ronica Smith. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Ronica Smith and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is an Adult Day Program. LPA observed the hallways to be cleared and free of debris. Covid-19 signs posted throughout the facility. Social distancing enforced. All clients and staff were observed wearing masks. Fire extinguisher was in compliance. LPA advised facility to fit-test staff in the event there is a client that becomes symptomatic.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with administrator to satisfaction.

Exit interview was conducted. No deficiencies cited and report emailed to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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