198600419-9-29-2023-28-AS-CWOG-CW5U5H-20230929151647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600419
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:17:52 PM

Document Has Been Signed on 09/29/2023 03:17 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 HOME II		FACILITY NUMBER:	198600419
ADMINISTRATOR:	HERNANDEZ, MARY ANN		FACILITY TYPE:	735
ADDRESS:	1203 BREA CANYON CUT-OFF ROAD		TELEPHONE:	(909) 595-5775
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 4	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Araceli Aguilar		TIME COMPLETED:	03:40 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 Araceli Aguilar 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 4G 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 client temperature , and staff disinfected the facility every shift and visitor screening and mask wearing. 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 room, kitchen, laundry room, staff bathroom, three clients bedrooms, two clients bathrooms and an attached garage/Staff Office. All three clients bedrooms have two beds, two night stands, two chairs, required furniture and beddings and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The two client's bathrooms hot water temperature were tested between 111.5 and 112.2 degrees F which are within the Tittle 22 regulation. All the appliances in the kitchen and living room are working properly. The sharp knives are stored and locked in the kitchen drawer. The cleaning supplies and chemicals are stored and locked under the sink and the locked cabinet in the laundry room. (See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 HOME II	FACILITY NUMBER: 198600419
	VISIT DATE: 09/29/2023

NARRATIVE

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The extra linen are stored in the staff office/garage. The extra personal hygiene products are stored in the cabinet in the staff bathroom. 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 kitchen and its working well.

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.

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

5. Personnel Records-Training: The facility staff files are stored in the staff office/garage. 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 5/31/23 and currently her administrator certificate is pending at the CCL system. The administrator has the updated HIV and TB Training certificate.

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/garage. 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.

8. Food Service: The facility has ample supply of 2 days perishable and 7 days non-perishable food supply. Currently no client is on any modified diet. All the food in the facility are stored probably.

(See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 HOME II	FACILITY NUMBER: 198600419
	VISIT DATE: 09/29/2023

NARRATIVE

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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 they seemed accurate and updated. All clients have 30 days supply of medication.

10. Incidental Medical and Dental Services: Currently there's one client is on restricted health condition plan. LPA reviewed client's restricted health condition plan and its updated. Staff reported there are two home health nurse comes regularly. One comes monthly. One comes weekly or as needed for check client's enema condition. Facility has no client with prohibited health condition.

11. Disaster Preparedness: The facility has an emergency disaster plan but its not updated. The last one was completed on 01/01/2020. 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.

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 Araceli Aguilar and a copy of this report is being provided and Appeal Rights were given.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 03:17 PM - It Cannot Be Edited

Created By: Christine Wong On 09/29/2023 at 02:40 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 HOME II	FACILITY NUMBER: 198600419
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(a)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on recored review, LPA observed the emergency and diaster plan was not updated and last completed was dated on 01/01/2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Administrator will submit an updated Emergency and Disaster Plan (LIC610D) to LPA 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: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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