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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600157
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:19:19 PM


Document Has Been Signed on 10/10/2024 01:19 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
MONTEREY PARK ASC, 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:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Veneranda Guiyab,Direct Support StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Mayra Cota and Mary Flores conducted an unannounced annual visit using the CARE Inspection Tool. LPAs met with Veneranda Guiyab and explained the reason for the visit.

Facility is licensed to serve four (4) developmentally disabled adults ages 18-59. Facility is approved for ambulatory only. Facility is a single home located in a residential area and consists of three (3) client bedrooms, two (2) client bathrooms, one (1) staff bedroom, living room/office area, dining area, kitchen, attached garage and front and backyard.

LPAs conducted a tour of the facility with Veneranda Guiyab and observed the following:

Facility was observed clean inside and out. Fireplace in the living room was observed to be covered. Furniture in living room and dining area was observed to be in good repair. Kitchen area was observed to be clean. Food supply was observed and has at least two (2) days of perishables and seven (7) days of no-perishables. Sharps, medication and cleaning supplies were locked in kitchen cabinets. One (1) fire extinguisher was observed and last checked on 10/3/2023. Three (3) client bedrooms were observed and all have the required bedding supplies, furniture in good repair and lighting is available. Two bathrooms were observed to be clean and in good repair. Water temperature was tested and yielded temperature between 112.2 - 113.0 degrees F. which is within the required temperature of 105 - 120 degrees F. LPAs observed sufficient linen supplies and grooming items. LPAs observed the outdoor environment and walkways were clear of obstructions. Shaded area was observed to have furniture for seating and awning is in good repair. No large bodies of water were observed. First aid kit was observed with all required items.

LPAs reviewed a total of four (4) client files and medication. P&I money was not reviewed as clients handle their own money. Five (5) staff files were reviewed. Administrator certificate was observed for Mary Ann Hernandez, #600742735 expiration date: 5/31/2025. (Continued on LIC 809C)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Mayra CotaTELEPHONE: (323) 980-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEHM HOMES, INC.
FACILITY NUMBER: 198600157
VISIT DATE: 10/10/2024
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 Infection Control Plan and Emergency Disaster Plan were reviewed. At the time of the visit, clients were at the Day Program, therefore, no interviews were conducted. One (1) staff was interviewed.

Exit interview was conducted with Venaranda Guiyab and a copy of this report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Mayra CotaTELEPHONE: (323) 980-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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