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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600419
Report Date: 12/15/2021
Date Signed: 12/15/2021 01:50:23 PM

Document Has Been Signed on 12/15/2021 01:50 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 HOME IIFACILITY NUMBER:
198600419
ADMINISTRATOR:HERNANDEZ, MARY ANNFACILITY TYPE:
735
ADDRESS:1203 BREA CANYON CUT-OFF ROADTELEPHONE:
(909) 595-5775
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 4DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Araceli Aguilar (Direct Support Staff)TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Araceli Aguilar (Direct Support Staff) and explained the purpose of the visit. The facility is licensed to serve four (4) developmentally disabled adults ages 18-59. Approved for ambulatory only.

The facility is located in a residential area. A tour of the single-story facility includes: Living room,dining area, kitchen, 3 bedrooms, 3 bathrooms, laundry room and an attached garage/storage/office.

During today’s visit, LPA observed the following: Licensee is not operating beyond the conditions and limitations specified on the license, including the capacity. All clients are protected against hazards. All outdoor and indoor passageways are free of obstruction. There are no pools or large bodies of water on the premises. There are no firearms on the premises and other dangerous weapons such as knives are locked in the kitchen cabinet. Disinfectants, cleaning solutions, poisons are inaccessible to clients. A comfortable temperature for clients is maintained. Lamps or lights in all rooms to ensure the comfort and safety were observed. Hot water temperature measured at 115.1 degree F in the bathroom next to the laundry room. All toilets, hand washing and bathing facilities is safe, sanitary and in operating condition. Hygiene products such as feminine napkins, non-medicated soap, toilet paper, toothbrush, toothpaste, and comb are readily available. The fire extinguisher was observed in the kitchen area and was fully charged. The first-aid kit is fully stocked w/First-aid Manual. All foods are selected, stored, prepared and served in a safe and healthful manner. Nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. Freezers and refrigerators are clean, and maintain temperatures. Sufficient staff as necessary to ensure provision of care and supervision to meet client needs were observed. All staff have a criminal record clearance and current first aid. The administrator is on the premises a sufficient number of hours necessary to adequately administer the facility. All medications are labeled and maintained in compliance with label instructions and State and Federal law. Medications are safe, locked and inaccessible. Smoke detectors and carbon monoxide detector are operational.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Araceli Aguilar.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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