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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600419
Report Date: 10/07/2022
Date Signed: 10/20/2022 04:08:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/20/2022 04:08 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:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Araceli Aguilar TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Araceli Aguilar and Venerana Guiyab and explained the reason of the visit and both DSP assisted LPA with the visit. LPA used the infection control to evaluated the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medication, observed food supply, and reviewed clients and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes living room, kitchen, dining area, three clients bedrooms, three clients bathrooms, laundry room and an attached garage. All 3 clients bedrooms were toured. Each bedroom has two beds, chairs, two drawers, required bed linen and furniture and sufficient lighting and closet space. All 3 clients bathrooms were toured and they were clean, sanitary and in a good working condition. LPA tested the hot water in all three bathrooms and they were measured between 114.3 and 117.3 degrees F. which is within the Title 22 regulation. The refrigerator and the kitchen cabinet and garage have 2 days perishable and 7 days non perishable food supply. All the appliance in the kitchen are clean and working properly. The common area such as living room and dining area are clean and have required furniture. The front and back yard are maintained well and the back yard has a shaded area with table and chairs for client to utilize. All the toxic and cleaning supplies are locked on top of the cabinet in the laundry room. The sharp knives and utensils are locked under the kitchen drawer. LPA also inspected the smoke detectors and carbon monoxide detectors and they are working properly.

LPA reviewed 4 clients files and all their emergency contact information are updated. LPA also interviewed 2 staff files and they are all finger print cleared and the health screening forms updated in the staff personnel file. LPA also inspected the 4 clients' medication and all seemed accurate and updated.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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 HOME II
FACILITY NUMBER: 198600419
VISIT DATE: 10/07/2022
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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 room and facility is disinfected every shift and daily, the clients' bathrooms have sufficient soap, paper towels and signs. PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to DSP Araceli Aguilar.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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