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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600157
Report Date: 07/27/2022
Date Signed: 07/27/2022 12:58:08 PM

Document Has Been Signed on 07/27/2022 12:58 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GEHM HOMES, INC.FACILITY NUMBER:
198600157
ADMINISTRATOR:MARY ANN HERNANDEZFACILITY TYPE:
735
ADDRESS:19790 SAND SPRING DRTELEPHONE:
(909) 598-4321
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Gloria Guiyab TIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with Direct Support Professional (DSP) Gloria Guiyab and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes living room, staff office dining area, kitchen, three clients bedrooms, one staff room, two bathrooms and attached garage. All 3 clients bedrooms were toured. Bedroom#1 and #2 has one bed, one night stand, required bed linen, furniture and sufficient lighting and closet space. Bedroom#3 has two beds, two night stands, required bed linen, furniture and sufficient lighting and closet space. All 2 bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water temperature in two bathrooms were tested between 114.4 and 114.5 degrees F which is within the Title 22 regulation. The refrigerator and the kitchen cabinet has sufficient 2 days perishable and 7 days non-perishable food supply. All the sharp knives and utensils are locked in the kitchen drawer. All the toxic and cleaning supplies are locked under the kitchen sink which is inaccessible to clients. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with tables and chairs for clients to utilize. LPA also inspected the smoked detectors and carbon monoxide detectors and they are all interconnected and working properly.

LPA reviewed 4 clients files to confirm emergency contact LPA also reviewed staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and updated in the file. LPA reviewed all 4 clients medications and they are all accurate and updated. They are all centrally stored and locked in the kitchen cabinet.

(SEE LIC 809C for Continuation)
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEHM HOMES, INC.
FACILITY NUMBER: 198600157
VISIT DATE: 07/27/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, the disinfecting products are available in each clients room and common area and facility is disinfected frequently , clients' bathrooms have sufficient soap, paper towels, and signs and PPE supplies are sufficient for more than 30 days

No deficiencies were observed during the visit. Exit interview conducted with Direct Support Professional (DSP), Gloria Guiyab, a copy of this report is being provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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