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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850135
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:48:51 PM

Document Has Been Signed on 12/13/2021 01:48 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:REM CALIFORNIA LLC - CHURCHFACILITY NUMBER:
425850135
ADMINISTRATOR:SALAZAR, RAQUELFACILITY TYPE:
775
ADDRESS:305 WEST CHURCH STREETTELEPHONE:
(805) 928-3414
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 45CENSUS: 8DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator Raquel SalazarTIME COMPLETED:
02:10 PM
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On 12/13/21 at 12:45 PM, Licensing Program Analyst (LPA) Toan Luong contacted the facility and performed a facility risk assessment with Administrator Raquel Salazar. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Raquel Salazar 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 observed CDSS PINs in a binder available in the hallway. LPA advised facility to fit test staff in the event a client becomes symptomatic. Facility has already scheduled staff to be fit tested on 12/15/21.

During today's inspection, LPA notified administrator of annual fee and obtained current facility contact information.

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: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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