425850135-12-11-2024-29-AS-EMIR-DBUVJJ-20241211152848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850135
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:28:57 PM

Document Has Been Signed on 12/11/2024 03:28 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	REM CALIFORNIA LLC - CHURCH		FACILITY NUMBER:	425850135
ADMINISTRATOR/ DIRECTOR:	SALAZAR, RAQUEL		FACILITY TYPE:	775
ADDRESS:	305 WEST CHURCH STREET		TELEPHONE:	(805) 349-7516
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 45		CENSUS:	DATE:	12/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Raquel Salazar, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:35 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Erika Miller arrived at 11:30 a.m. to conduct a 1-year required annual visit. LPA met with Raquel Salazar, program director and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Infection Control: The facility has a current Infection Control Plan. The facility has at least a 30-day supply of PPE. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Physical Plant & Environment Safety: LPA toured the facility and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for client comfort. Toilet and hand washing facilities are operational. Disinfectant and cleaning solutions are inaccessible to clients in care and are locked in utility closet in the courtyard. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The fire extinguisher was last charged and inspected on 11/5/24. The facility has smoke and carbon monoxide detectors that were tested and are working properly.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 45. The fire clearance is granted for 45 ambulatory clients. The facility currently has 19 ambulatory clients enrolled.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REM CALIFORNIA LLC - CHURCH	FACILITY NUMBER: 425850135
	VISIT DATE: 12/11/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staffing: The facility currently employs 9 full time staff and 4 managers. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Fingerprint clearance/Associations/exemptions.

Personnel Records & Training: The facility keeps confidential files for each staff member.

Resident Records & Incident Reports: The facility keeps separate files on each client confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 client files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, (TCRC IPP) Emergency and ID forms. All forms were legible.

Food Service: The facility provides either an AM or PM snack to clients. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: The facility uses the Centrally Stored Medication and Destruct Records (CSMDR) and Medical Administration Record (MAR). LPA reviewed resident medications, no labels were altered, no medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a fire drill on 11/25/24. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Exit interview conducted and copy of report printed for Program Director.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2