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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600473
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:53:27 PM

Document Has Been Signed on 01/21/2025 01:53 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/
DIRECTOR:		RODRIGUEZ, GEMMA A.FACILITY TYPE:
735
ADDRESS:1309 LA SERENA DRIVETELEPHONE:
(909) 967-6966
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:57 AM
MET WITH:Gemma Rodriguez, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Gemma Rodriguez, Administrator, and explained the reason for the visit.

The facility is licensed to served six (6) ambulatory clients only, developmentally disabled adults ages 18-59. Facility is a single home located in a residential neighborhood, and consist of a kitchen, a dining room, a living, 3 client bedrooms, 1 client bathrooms, laundry, a staff bedroom and bathroom, a garage, a front yard, and a back yard.

LPA conducted a tour of the facility observed the following:
Facility water heater is leaking and there are piles of leaves in the yard. Kitchen was observed clean, cleaning supplies, medications, and sharps are in locked cabinets in the kitchen area. Sufficient food was observed for at least 2 days of perishables, and 7 days of non-perishables. All common areas have sufficient furniture which is in good repair. Bathroom sink was backed up. Each client bedroom has all the required furniture, bedding supplies, and sufficient lighting. and water temperature was tested between 107.7-110.4 degrees F., which is within the required 105-120 degrees F. All exit doors are clear. Passageways are clear of obstructions. back of home has a covered seating area. No large bodies of water were observed. Carbon monoxide/Smoke detectors were observed, but two in client’s bedrooms were not in working condition. Fire extinguisher was observed and operable.
LPA reviewed medication, files, for four (4) clients and reviewed five (5) staff files. Administrator certificate was observed for Gemma Rodriguez exp. date: 03/17/2026.
Emergency Disaster plan was reviewed, and needs updating, and Infection Control plan was observed but those do not meet the new Infection Control regulations. Therefore, administrator will submit an updated infection control plan to the department.

Deficiencies were noted during this visit. A technical violation was noted. Exit interview was conducted with administrator and a copy of this report was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/21/2025 01:53 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/21/2025 at 01:04 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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) (interview) (record review)], the licensee did not comply with the section cited above. two carbon monoxide detectors are not working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Administrator will repair or replace two carbon monoxide detectors and send proof to LPA by POC 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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/21/2025 01:53 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/21/2025 at 01:04 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water heater is leaking water, and leaves are piled up in yard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator will remove leaves, dispose of them, and repair the water heater and send proof to LPA BY POC date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The sink in the back is backed up which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator will repair sink so that it drains properly.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/21/2025 01:53 PM - It Cannot Be Edited


Created By: Alberto Lopez On 01/21/2025 at 01:04 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

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. Facility has four clients (C1-C4) that need the LIC 602 for elderly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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Administrator will obtain LIC 602 for clients over 60. (C1-C4)
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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