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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600473
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:13:21 PM

Document Has Been Signed on 01/11/2024 03:13 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: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: 6DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Gemma Rodriguez- AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Gemma Rodriguez, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (6) client medications, (6) client files, (3) staff files, and conducted interviews with (3) staff. LPA attempted to interview (2) clients and was unable to to conduct interviews with (2) other clients due to clients being out of the home at the time of the visit. The facility is a single-story home, operating as an Adult Residential Facility. It is licensed to serve (6) developmentally disabled adults, ages 18-59, which all may be ambulatory, only. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review.
LPA observed (3) client bedrooms and (1) live-in staff bedroom. Client bedrooms had the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home. (1) is designated for staff, (1) designated for clients. Both bathrooms are equipped with a toilet, shower, and wash basin. The hot water was tested and measured between 109*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. First aid kit and manual were observed- available and complete. No bodies of water were observed on the premises. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to clients in care. The last fire drill was conducted on 01/01/2024. LPA did not observe a carbon monoxide detector in the facility at the time of the visit. Per Administrator, it was taken down due to the walls being painted and was misplaced. (4) client files and (3) staff files were reviewed and observed to be complete with all required documentation. (4) client medications were reviewed and were observed to be documented properly and given as prescribed.
Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC809-D page.
An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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Document Has Been Signed on 01/11/2024 03:13 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 01/11/2024 at 03:06 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee failed to maintain a carbon monoxide detector available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2024
Plan of Correction
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Licensee will submit to LPA, via email, a picture of an installed carbon monoxide detector and a purchase receipt for it, by 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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