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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600473
Report Date: 12/19/2022
Date Signed: 12/19/2022 12:27:21 PM

Document Has Been Signed on 12/19/2022 12:27 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:GEMLY'S HOME CAREFACILITY NUMBER:
198600473
ADMINISTRATOR:RODRIGUEZ, GEMMA A.FACILITY TYPE:
735
ADDRESS:1309 LA SERENA DRIVETELEPHONE:
(909) 967-6966
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Licensee, Gemma RodriguezTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Sheryl Seguin (Direct Support Professional/DSP) and discussed the purpose of today's visit. The facility cares for Developmentally Disabled clients ages 18-59 ambulatory only. Current clients' census is (5) ambulatory. One (1) client has just been cleared of covid and another one (1) is still at the Hospital, admitted due to medical issue. At 10:45am, Licensee Gemma Rodriguez and Administrator Ulysis Rodriguez arrived and LPA explained the purpose of today's visit. Both assisted with the inspection. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, staff/clients files and observed food supply. This single-story home contains four (4) bedrooms, two (2) bathrooms, a living room, kitchen, dining area, enclosed patio/activity area, backyard, and detached garage.

The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE supplies, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility.
  • Staff wore face masks throughout their shift.
  • Facility maintained a 30-day supply of PPE located in the supply closet and garage.
  • At 10:15am, the kitchen was inspected. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All the appliances are clean and are working properly.
  • Cleaning solutions and sharps were locked and inaccessible to clients.
  • The laundry room is located in the patio area, it was clean and has cleaning supplies locked and inaccessible to clients.
  • At 10:55am, hot water temperature was measured in kitchen and bathrooms. Kitchen read at 142.8 deg F, bathroom #1 water temperature read 138.2 deg F and bathroom #2 read 139 deg F. Administrator immediately adjusted water meter and all areas measured within 105-120. New reading at 11:09am: kitchen read at 110.4 deg F, bathroom #1 water temperature read 105.2 deg F and bathroom #2 read 106 deg F.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEMLY'S HOME CARE
FACILITY NUMBER: 198600473
VISIT DATE: 12/19/2022
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  • Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space.
  • Bathrooms have the required grabs bars, non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, centrally stored, and given as prescribed. Medications were reviewed for all (5) clients and facility maintained a 30-day supply of medications.
  • The common areas such as living room, activity room and dining room are clean and have the required furniture. Furniture and group activities were spaced to encourage physical distancing.
  • The enclosed patio has sufficient tables and sitting area. It is designated as the visitor area during the COVID-19 pandemic.
  • There is one (1) fire extinguisher in the facility and observed to be newly purchased (12/07/2022). There are no bodies of water or cameras present.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Clients files were reviewed to confirm emergency contact is updated and clients have health screenings and or vaccinations
  • Staff files were inspected and contained required health screenings, criminal record clearances, and training certificates.
  • Administrator certificate expired on 10/01/2022 (certificate # 6007753735). Licensee sent the renewal application on 9/01/2022 and sent payment to Dept. of Social Services (DSS) by check, dated 9/16/2022. Licensee will send a copy of the renewed Administrator certificate once received.


Deficiency was cited and Technical Assistance issued on separate LIC809-D and LIC9102 forms.

An exit interview was conducted, and a copy of this report and appeal rights were provided to the Licensee, Gemma Rodriguez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2022 12:27 PM - It Cannot Be Edited


Created By: Bennette Pena On 12/19/2022 at 12:01 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: GEMLY'S HOME CARE
FACILITY NUMBER: 198600473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, ..... the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in which (4) out of (5) clients in care are over 59 years old which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/04/2023
Plan of Correction
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Licensee will send an exception request letter for (2) clients who are currently residing in the facility. Request letter along with other information will be emailed to LPA Pena on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022


LIC809 (FAS) - (06/04)
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