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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850135
Report Date: 11/27/2023
Date Signed: 11/27/2023 01:15:16 PM

Document Has Been Signed on 11/27/2023 01:15 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
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) 349-7516
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 45CENSUS: 16DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Raquel Salazar, AdministratorTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Olson arrived at the facility unannounced to conduct a required annual visit at 9:40 a.m. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Miguel Magana. LPA and QAS met with Administrator and explained the reason for the visit. The program currently operates from 9:00 a.m. to 3:00 p.m.

Common Activity Space: The facility is a single-story structure with a conference room, office, relaxing/multipurpose room, three (3) bathrooms, and a large open program area. LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. Carbon monoxide and smoke alarm detectors were tested and functioned properly during time of visit. LPA observed fire extinguishers throughout the facility, which were last serviced 11/03/2022.

Activities: Activities are both designed for individuals and as a group. Some clients do day outings.

Food Service: Clients bring their lunch and snacks. The facility has emergency water, food supplies and snacks available for consumers.

Restrooms: Restrooms were clean and sanitary and stocked with soap and paper towels. At 12:30 p.m., water temperature in the kitchen was measured at 121.5 degrees Fahrenheit.

Record Review: Around 9:45 a.m. a review of facility files was initiated. LPA obtained Client Roster and Staff Roster. LPA reviewed five (5) of (16) Client Files. LPA reviewed five (5) of (12) staff files. All staff and client files were complete.

Medications: Medications are centrally stored and locked in a cabinet in the office. Medications are labeled and checked for expiration dates. Medications could use better documentation on the centrally stored medications and destruction record.

Report will continue on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - CHURCH
FACILITY NUMBER: 425850135
VISIT DATE: 11/27/2023
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Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.

Interview: During today's visit, the LPA interviewed two (2) staff. All other staff and clients were out in the community. No immediate concerns voiced at this time.

Exit interview conducted and copy of the report was printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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