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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606868
Report Date: 02/23/2022
Date Signed: 02/23/2022 12:18:52 PM


Document Has Been Signed on 02/23/2022 12:18 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:GUMA RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
197606868
ADMINISTRATOR:VIRGINIA GUMAYAGAYFACILITY TYPE:
740
ADDRESS:544 WEST AVENUE J-15TELEPHONE:
(661) 579-6039
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:VIRGINIA GUMAYAGAYTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver, Cresencia SanSano and then greeted by Administrator Virginia Gumayagay who were both wearing masks. LPA observed the COVID signs posted on the front door. LPA's temperature was taken and LPA observed the sign in station which contained sign in sheet, hand sanitizer and available masks. The Administrator confirmed there are two residents. LPA observed the living room/dining room and kitchen combination. LPA began the tour at 10:45 am. The kitchen was neat and clean and LPA observed the caregiver preparing the noon meal.

At 10:55 am, LPA observed hand soap, paper towels, and trash can located in the kitchen. LPA also observed the cleaning products were not locked and were stored under the sink. Also, the knives were not locked. Administrator stated repair work had taken place and the locks were not working. LPA observed an adequate supply of canned goods in the pantry and a five-day supply of fresh vegetables and fruits in the refrigerator. The freezer section also contained frozen meats. At 11:05 am, LPA observed the medications were locked in a cabinet within the kitchen area. LPA observed the live in staff room at the back of the facility and LPA walked outside and observed the backyard gate was not locked. LPA observed caregiver's husband, Apolinario Sansano in the backyard. Administrator and caregiver both confirmed husband does not care for the residents but has cleared background. LPA Spaeth confirmed both caregiver and husband has cleared background.

LPA observed the bathroom which contained wash your hands sign, hand soap, and a trash can. Cleaning products were stored in an unlocked cabinet underneath the sink. LPA stated to Administrator and Caregiver that the cleaning products must be moved to a locked cabinet. LPA observed the two residents' rooms and both were sleeping. LPA observed the locked garage which contained the washer, dryer, and an additional refrigerator. The refrigerator contained additional food items. Pursuant to Title 22 Division 6 of the CA Code of Regulations, two deficiencies were cited (refer to LIC 809-D). Exit inteview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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Document Has Been Signed on 02/23/2022 12:18 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: GUMA RESIDENTIAL CARE FOR THE ELDERLY
FACILITY NUMBER: 197606868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2022
Section Cited

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(a) Disinfectants, cleaning solutions, poisons... which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is evidenced by:
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LPA Spaeth observed the cleaning solutions were not securely locked in the kitchen and bathroom cabinets which poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
03/04/2022
Section Cited

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(f) The following shall be stored inaccessible to residents... (1) Knives, matches,.... that could constitute a danger to the resident(s). This requirement is not evidenced by:
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LPA Spaeth observed the knives were not securely locked in a cabinet which poses an immediate health, safety, and personal rights risk to residents in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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