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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850134
Report Date: 11/25/2024
Date Signed: 11/25/2024 01:00:49 PM

Document Has Been Signed on 11/25/2024 01:00 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - LOMPOCFACILITY NUMBER:
425850134
ADMINISTRATOR/
DIRECTOR:		SMITH, RONICAFACILITY TYPE:
775
ADDRESS:1133 NORTH H STREET SUITE FTELEPHONE:
(805) 757-9595
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 45CENSUS: 10DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ronica Smith, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 11/25/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unannounced evaluation visit. When the LPA arrived, they were greeted by Administrator Ronica Smith. LPA informed facility representatives of the reason for the visit upon entry.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is an Adult Day Program (ADP). This facility has an approved fire clearance for a maximum capacity of forty-five (45) clients, ten (10) of which may be non-ambulatory.

The facility is an Adult Day Program (ADP) and does not have a main kitchen for clients of the facility. The facility does have an area constituting the meal/snack area for clients during the day from 8:30am-2:30pm Monday-Friday. This area has a microwave, toaster oven, refrigerator, and various utensils/items for the preparation of snacks. LPA inspected the food service areas in the facility and observed that items which could constitute a danger to residents are kept inaccessible to residents in the kitchen area. All appliances were in operable condition and looked clean/in good repair.

The facility maintains a main entrance lobby with sign in materials as well as COVID screening procedures. The facility has multiple Staff office rooms with desks, computers, storage cabinets, etc. The facility has two (2) large conference rooms that can hold all clients, sensory room, library, game room, woodworking room, media room, and garden room. There are no fireplaces on the premises. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintains a pool table, woodworking materials, gardening materials, puzzles, games, and multiple rooms for client activity. The facility maintained a comfortable temperature in all areas inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected were fully charged and serviced annually. The LPA observed required postings throughout all common spaces. There are activity supplies and equipment, including reading, game, and media materials for the clients in all common areas inspected. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - LOMPOC
FACILITY NUMBER: 425850134
VISIT DATE: 11/25/2024
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All window screens were in good repair in all the areas comprising the facility. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all ramps are well-lit with sturdy hand railings/stair chair accessibility devices. This facility is one (1) story throughout and therefore there are no stairways for clients to utilize. Facility is an Adult Day Program (ADP), there is no signal system in place which was functional at the time of the inspection by the LPA.

The facility is completely enclosed with a main entrance door and an emergency exit at the rear of the facility. There is a main entrance into the facility inside of a mini mall area on a public street. The facility has walls surrounding the interior of the facility. There are no bodies of water on the facility premises. There are no outdoor activity spaces for clients equipped with furniture for client use as this is an Adult Day Program (ADP) with facility transportation vehicles. This is an ADP facility, therefore there is not a designated laundry room with the storage of cleaning products. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. There is a first aid kit that include sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport clients are in safe operating condition with appropriate insurance information.

The facility does not have client bedrooms as this is an Adult Day Program (ADP) with a client schedule of Monday-Friday 8:00am-2:30pm. The entire interior of the facility is furnished with a smoke alarm/fire alarm system, emergency sprinklers, and appliances for the clients. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are three (3) restrooms in the common areas of the facility that included soap, paper towels, required postings, and clean trashcans with closed lids. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per client in the facility. Nightlights are not necessary to be installed as the clients are only in the facility from 8:00am-2:30pm Monday-Friday.

An emergency exiting plan and emergency phone numbers are posted in an appropriate place. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REM CALIFORNIA LLC - LOMPOC
FACILITY NUMBER: 425850134
VISIT DATE: 11/25/2024
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Administrator’s records, employees and client records are maintained at the facility and available for review by the LPA as employees are hired and clients accepted into the facility. The facility complies with Licensing Agency standards for health screening, TB clearance, staff training, and criminal background/record clearance requests. Licensing regulations require Any staff person, volunteer, or employee who has contact with the clients and is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification prior to employment, residence, or initial presence in the facility. The facility above has one (1) current employee/staff member who needs a required criminal record exemption and has a determination of not eligible. The Department of Justice (DOJ) has disqualified the employee from obtaining a background clearance. LPA conducted record review and found that the Background check exemption request/eligibility information from Guardian was sent to the wrong facility mailing address and was not received by administrator of the facility above. LPA completed a facility mailing address change during this annual evaluation visit to correct the error and make sure facility receives all pertinent documentation/information. Admission agreements and needs and services (ANS) plan are maintained for each client and/or their authorized representative. Client records are maintained on the facility premises in a secured area. Facility does not maintain centrally stored medications as no clients at the facility that take or must take any medications while at the Adult Day Program (ADP) facility from 8:30am-2:30pm Monday-Friday. Provider Information Notices are available and able to be presented to Staff, clients, visitors, and accessible to LPA upon request during the inspection process.

No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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