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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440602
Report Date: 06/23/2021
Date Signed: 06/23/2021 06:31:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GM RESIDENTIAL CARE HOMEFACILITY NUMBER:
011440602
ADMINISTRATOR:CHILIN, GRICELDA G.FACILITY TYPE:
740
ADDRESS:4924 OMAR STREETTELEPHONE:
(510) 226-0102
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 5DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Gricelda Chilin, LicenseeTIME COMPLETED:
06:45 PM
NARRATIVE
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On 6/23/2021 at 3:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Licensee, Gricelda Chilin and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, and common areas. LPA observed hand washing and COVID-19 symptoms posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations.

During record review, LPA observed temperature log for residents. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

At 3:30PM, LPA observed unlocked medications in the hall closet.
At 3:40PM, LPA observed unlocked knives and gardening tools in the back yard.
At 3:50PM, LPA interviewed licensee/administrator and observed facility have not been following CCLD guidelines for infection control including mask wearing, visitor's log, staff testing, documenting staff temperature, and some COVID-19 postings.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GM RESIDENTIAL CARE HOME
FACILITY NUMBER: 011440602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked knives and gardening tools in the backyard which poses an immediate health and safety risk to residents in care.
POC Due Date: 06/24/2021
Plan of Correction
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Licensee have locked up the knives and gardening tools during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having unlocked medication in the hallway closet which poses an immediate health and safety risk to residents in care.
POC Due Date: 06/24/2021
Plan of Correction
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Licensee have locked up the medications during inspection.

Deficiency cleared during inspection.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GM RESIDENTIAL CARE HOME
FACILITY NUMBER: 011440602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)(2)
Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed staff not wearing a mask, routine screening is not being documented for staff, staff surveilance testing, a visitor sign-in policy is not being maintained, and some CCLD posting is not posted in common areas which poses a potential health and safety risk to residents in care.
POC Due Date: 06/30/2021
Plan of Correction
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Administrator has agreed to conduct training to all staff on current CCLD guidelines/PINs, maintaining visitation log, document staff daily screening, staff surveilance testing, and post CCLD postings in common areas. Administrator will provide self certification to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9