198600157-12-7-2023-28-AS-CWOG-CYATYY-20231207140932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600157
Report Date: 12/07/2023
Date Signed: 12/07/2023 02:10:31 PM

Document Has Been Signed on 12/07/2023 02:10 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GEHM HOMES, INC.		FACILITY NUMBER:	198600157
ADMINISTRATOR:	MARY ANN HERNANDEZ		FACILITY TYPE:	735
ADDRESS:	19790 SAND SPRING DR		TELEPHONE:	(909) 598-4321
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 4	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Veneranda Guiyab		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Veneranda Guiyab and explained the reason of the visit. The facility is approved for serve for four (4) Developmentally Disabled Adults ages 18-59, approved for ambulatory only. The facility is licensed as a Level 3 home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing, checking clients and visitor temperature , and staff disinfected the facility every shift or as needed and visitor screening and mask wearing. The facility also has sufficient PPE supplies. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, staff office, kitchen, two bathrooms, three clients bedrooms, staff break room and an attached garage. Bedroom#1 and #2 has one bed, one night stand, one chair, required bed linen and furniture and sufficient lighting and closet space. Bedroom#3 has two beds, two chairs, two night stands and required bed linen and furniture and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature tested in both bathrooms were 108.5 and 109 degrees F. which are within the Title 22 regulation. All the appliances in the kitchen and living room are working properly. The sharp knives and utensils are stored and locked in the kitchen drawer.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GEHM HOMES, INC.	FACILITY NUMBER: 198600157
	VISIT DATE: 12/07/2023

NARRATIVE

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All the cleaning supplies and chemicals are stored and locked under the sink and garage cabinet. The extra linen are stored in the hallway cabinet. The extra personal hygiene products are stored in the garage cabinet. The hallway night will always on during night time for client to access the non-private bathrooms. The facility has a land line telephone system for client to use. The passageway, walkway and patio are free of obstruction. LPA inspected the carbon monoxide detectors and it's mounted on the wall near the staff office and it's working properly. The smoke detectors are located in each bedroom and common area and they are working well too.

3. Operational Requirement: The facility is licensed for four (4) ambulatory only. Currently all the clients in the facility are ambulatory. The facility patio has a shaded area with table and chairs for client to use for outdoor activity. The client also has an opportunity to attend the community activities if needed. The last disaster drill was conducted on 11/27/23.

4. Staffing: The facility has sufficient staffing in the facility. LPA reviewed the NOC Shift staff and she has the required the facility planned emergency procedure training.

5. Personnel Records-Training: The facility staff files are stored in the staff office near the living room. All staff are over 18 years old, fingerprint cleared and associated with the facility. LPA reviewed three (3) staff files and all staff files have the required documents included: Health screenings, TB test result, required training hours and updated First Aid Certificate. The facility Administrator is Mary Ann Hernandez and her administrator certificate expiration date on 5/31/25. The administrator has the updated HIV and TB Training certificate in file.

6. Client's Right-Information: Currently no clients in the facility required any postural support.

7. Client's Record-Incident Reports: All the clients files are stored in the staff office near the living room. LPA reviewed all four (4) clients' files and they all have the required documents including: face sheet, admission agreement, updated physician report, TB test result, functional capabilities assessment, Individual Program Plan (IPP), ambulatory status and medication list.

(See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GEHM HOMES, INC.	FACILITY NUMBER: 198600157
	VISIT DATE: 12/07/2023

NARRATIVE

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8. Food Service: The facility has ample supply of 2 days perishable and 7 days non-perishable food supply. Currently no client is on modified diet that prescribed by the primary physician. All the food in the facility are stored properly.

9. Health Related Services: The facility staff assists clients with their dental and medical appointment and provide transportation for them. LPA inspected all four (4) clients medication and LPA observed Client#1 (C1) 's today AM medication, staff did not dispense the medication to C1. LPA also reviewed the first aid supplies in the facility and they have all the required items.

10. Incidental Medical and Dental Services: Currently there's no client is on any restricted health condition plan and no client has any prohibited health condition in the facility.

11. Disaster Preparedness: The facility has an emergency disaster plan and its updated on 10/1/23. The last disaster drill was conducted on 11/27/23. The facility does have two alternative temporary shelter location.

12. Emergency Intervention: The facility does not use any restraints on clients but all staff received CPI training and they all have updated CPI training certificate.

The following deficiencies are being cited on the attached LIC 809D page, California Code of Regulations, Title 22, Division 6, Chapter 1.

Exit interview conducted with DSP Veneranda Guiyab and a copy of this report is being provided and Appeal Rights were given.

(Due to all clients are in the day program or work and LPA was not able to conduct any interviews with clients)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/07/2023 02:10 PM - It Cannot Be Edited

Created By: Christine Wong On 12/07/2023 at 01:37 PM

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GEHM HOMES, INC.	FACILITY NUMBER: 198600157
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reivew, LPA reviewed Client#1's medication and observed all C1's AM medication was not popped and staff did not dispense to client#1 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	The administrator will notify Client#1 family doctor and also provide medication trianing to all staff and send the staff training log to LPM by POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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