428209725-5-26-2022-34-CR-EMHZ-CESQHH-20220526121109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 428209725
Report Date: 05/26/2022
Date Signed: 05/26/2022 12:11:18 PM

Document Has Been Signed on 05/26/2022 12:11 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,
, CA

FACILITY NAME:	REM CALIFORNIA, LLC - TOPAZ		FACILITY NUMBER:	428209725
ADMINISTRATOR:	DANNY RABARA		FACILITY TYPE:	730
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	6	CENSUS: 4	DATE:	05/26/2022
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Facility Administrator		TIME COMPLETED:	12:30 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	On 5/26/2022 at 9:00am Licensing Program Analyst (LPA) Enrique Hernandez conducted an annual/Required inspection at REM California, LLC-Topaz v. LPA met with Danny Rabara Facility Administrator and Colleen Nawrot Program Director who granted access to the facility and toured the home in and out. This is a three-bedroom, two-bathroom, single story family residence that includes a living room, dining area, office area, kitchen, laundry area and an attached garage. LPA toured the entire facility and observed the following: Bedroom #1 is occupied by one male client, it has one twin size bed, adequate closet space, there’s no clothes in the client’s room due to that client #1 (C1) rips all the clothes. FA stated that he will get the documentation from the Regional Center regarding not having the client’s clothes in C1’s room. Bedroom #2 is occupied by one male client, it has one queen size bed, adequate closet and drawer space. Bedroom #3 is occupied by two male clients, it has one twin size bed, and one full size bed adequate walking closet and drawer space bathroom was clean at the time of the inspection. [See LIC811 Confidential Names List form (LIC811), dated 05/26/2022, for names] Kitchen/Dining area: There was one (1) refrigerator, microwave, one (1) stove one (1) with five (5) burners, all operable at the time of the inspection. There was a large dining table with four (4) chairs. A trash can with a lid on was observed in the kitchen area. LPA observed four (4) spoiled bananas and a lemon cut in half seating in the kitchen counter. Laundry Room: There was a laundry room in the garage equipped with a sink, one (1) washer and one (1) dryer during the time of the inspection. Continue on LIC809-C

SUPERVISOR'S NAME: Kevin C Sauk	TELEPHONE: (310) 391-8922
LICENSING EVALUATOR NAME: Enrique M Hernandez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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,
, CA

FACILITY NAME: REM CALIFORNIA, LLC - TOPAZ	FACILITY NUMBER: 428209725
	VISIT DATE: 05/26/2022

NARRATIVE

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Living Room: The area has a tv mounted on the wall. LPA observed worn sofas. FA stated that they will place an order today with the executive assistant.
Meds are locked and accessible only to employees supervising stored medications. Home has working smoke alarms, carbon monoxide detectors and working fire extinguishers at the time of this inspection. The home is equipped with two (2) bathrooms were operable at time of inspection. The facility has a working telephone/landline. There is no bodies of water on the premises.
LPA observed non-perishable foods for one week and perishable food for two days. Facility is clean and sanitary. Passageways, stairways, inclines, ramps, and open porches are unobstructed. Rules, regulations, licenses, emergency disaster plan and personal rights are posted at the facility. Menu is posted in the kitchen. Outdoor space is free of debris and hazard. Hazardous and cleaning solutions, disinfectants, poisons, medication and sharp knives are inaccessible to the clients.

The facility has a Chrysler Pacifica 2020 to transport clients. Current automobile insurance is with National Union Insurance Company.

Due to time constraints, LPA will return to review the client/staff files in order to complete the

Per California Code of Regulations, Title 22 Regulations, Division 6, chapters 5, no deficiencies are cited at this time

Exit interview was conducted and a copy of this report will be emailed to the facility Administrator due to technical difficulties with LPA’s printer.

SUPERVISOR'S NAME: Kevin C Sauk	TELEPHONE: (310) 391-8922
LICENSING EVALUATOR NAME: Enrique M Hernandez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/26/2022 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: REM CALIFORNIA, LLC - TOPAZ	FACILITY NUMBER: 428209725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in the living room both sofas look worn. Facility Administrator stated thats something they been discussing with the Executive Assistant to purchase new sofas. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2022
	Plan of Correction
1 2 3 4	LPA discussed the deficiency with facility administrator and Program Director in which both agreed. A written plan of correction shall be submitted to LPA Hernandez by 6/13/2022 indicating what steps will be implemented at the facility to ensure the facility is in good repair at all times.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kevin C Sauk	TELEPHONE: (310) 391-8922
LICENSING EVALUATOR NAME: Enrique M Hernandez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC809 (FAS) - (06/04)

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