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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600731
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:13:14 PM

Document Has Been Signed on 07/18/2024 04:13 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:GABRIELLA MOTHERLY CAREFACILITY NUMBER:
198600731
ADMINISTRATOR/
DIRECTOR:		VIVIAN ORTIZ-LUISFACILITY TYPE:
735
ADDRESS:3249 GABRIELLA STREETTELEPHONE:
(626) 964-6665
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:16 PM
MET WITH:Renato Madrigal, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to Victor Taclob. Licensee Renato Madrigal arrived shortly after. The facility serves developmentally disabled residents under age 59, and is licensed as a level 3 Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 4 resident bedrooms, 1 live-in staff room, 2 bathrooms, kitchen, dining room, living room, laundry area in attached garage, and outdoor shaded patio area. The facility has a fire pull-alarm system. The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility staff are using appropriate hand hygiene cleaning and disinfecting the home. An Infection Control Plan was reviewed.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fully charged fire extinguisher. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins were locked.

A kitchen drawer had a knife and pair of scissors that were unlocked, accessible to residents in care. Staff immediately locked the items in the regular sharps storage area.

Operational Requirements: Fire clearance is approved for four (4) ambulatory only residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond expires 5/16/2024.



Staffing: A total of four (4) staff members provide care and supervision to the clients.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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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: GABRIELLA MOTHERLY CARE
FACILITY NUMBER: 198600731
VISIT DATE: 07/18/2024
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Personnel Records/Staff Training: Four staff files were reviewed. Criminal background clearance, in-service training, 1st Aid/CPR training, and health screening. Staff (S5 & S6) have expired Pro-Act training.

Administrator certificate expired 5/18/2024. Licensee's Administrator certificate expired 6/20/2024. Administrator and Licensee provided proof that certificate renewal training was submitted and is currently pending processing.

Resident Rights/Information: Resident Personal Rights poster is posted in the dining area. Internet access is available for residents. Physician's orders are on file. No residents require modified diets. HCBS Rights are on file.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records. Files have been updated with HCBS Tenant/Landlord Rights and Responsibilities Agreement.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. 30-Day supply of medications were observed. Medications are given according to Physician directions. However, resident (R1) Rx Clonidine HCL 0.2 mg tab Noon medication date (7/18/2024) was still in bubble pack at 2:00 pm and a loose pill was observed in the med plastic container.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: LIC 610D form "Emergency Disaster Plan/Disaster and Mass Casualty Plan is current. The last Fire/Emergency Drill was conducted on 7/2/2024.

Emergency Intervention: No manual restraints, seclusion, or de-escalation techniques are used.

Per Title 22 deficiencies were cited.



Exit interview was conducted with Licensee Renato Madrigal. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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Document Has Been Signed on 07/18/2024 04:13 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/18/2024 at 03:56 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: GABRIELLA MOTHERLY CARE
FACILITY NUMBER: 198600731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in that an unlocked kitchen drawer had an knife and pair of scissors accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care. *Staff immediately locked the items in the regular sharps storage area.
POC Due Date: 07/19/2024
Plan of Correction
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Administrator shall submit proof of staff training by tomorrow.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, the licensee did not comply with the section cited above because resident (R1's) Rx Clonidine HCL 0.2 mg tab Noon medication date (7/18/2024) was still in bubble pack at 2:00 pm and a loose pill was observed in the med plastic container, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Administrator shall:
1. Contact MD and Regional Center about day program not administering noon medidcation, and dosage time frames. Submit proof that the above parties were contacted.
2. Provide staff training regarding medication administration procedures.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


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