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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191671053
Report Date: 04/19/2022
Date Signed: 04/19/2022 03:06:30 PM

Document Has Been Signed on 04/19/2022 03:06 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:GAMIO GROUP HOMEFACILITY NUMBER:
191671053
ADMINISTRATOR:GAMIO, CLAUDIAFACILITY TYPE:
735
ADDRESS:21528 RONAN AVE.TELEPHONE:
(310) 834-3918
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 3DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Claudia Gamio TIME COMPLETED:
12:21 PM
NARRATIVE
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On 04/19/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with licensee and administrator Claudia Gamio and explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory clients ages 18 through 59. The clients are Harbor Regional Center consumers.

The facility is a two story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, (2) staff bedrooms, two client's bathroom (2) , (1) staff bathroom, living area, dining area, kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 110.7 F. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Several fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) and Fire Drills were reviewed.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: GAMIO GROUP HOME
FACILITY NUMBER: 191671053
VISIT DATE: 04/19/2022
NARRATIVE
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DEFICIENCIES:
At 10:07 am LPA observed disenfetant cleaning hazardous materials under the kitchen sink was exposed to clients in care unlocked. At 10:08 am LPA observed the dishwasher, stove range, and refrigerator were remnants of dirt and grime. At 10:10 LPA observed the lower bathroom unsanitary with full waste materials on the floor, dirty towels on vanity, and spider webs over the shower. The lower bathroom also had rotted wood baseboards that is unsafe and unsanitary that will require replacement or repair.

INFECTION CONTROL:
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed.

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

Deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Claudia Gamio.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/19/2022 03:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/19/2022 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GAMIO GROUP HOME
FACILITY NUMBER: 191671053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(b)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following:

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 in the kitchen cabinet stored disenfectant cleanign solutions and other hazardous material were exposed to client's in care. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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The licensee will ensure that all hazardous materials are kept/stored in locked cabinets inaccessible to clients in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/19/2022 03:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/19/2022 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GAMIO GROUP HOME
FACILITY NUMBER: 191671053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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
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Based on [(observation), the licensee did not comply with the section cited above and identified lower bathroom baseboard with rotten wood that needs to be replaced or repaired. The violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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The Licensee will adhere to to Title 22 reguations and repair/replace the baseboard by POC date.
Type B
Section Cited
CCR
80087(a)(1)
Building 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 dirty referigarator, stove, dishwasher, lower bathroom unsanitary. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations and do some deep cleaning of kitchen and bathrooms by POC date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/19/2022 03:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/19/2022 at 11:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GAMIO GROUP HOME
FACILITY NUMBER: 191671053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above and failed to conduct regular disaster/fire drills on quarterly basis. The last fire drill was on 08/25/21. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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The licensee will adhere to Title 22 regulations and ensure that quarterly disaster/fire drills are conducted and documented.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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