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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600909
Report Date: 12/05/2022
Date Signed: 12/05/2022 02:45:34 PM

Document Has Been Signed on 12/05/2022 02:45 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 CARE IIFACILITY NUMBER:
198600909
ADMINISTRATOR:GEMMA RODRIGUEZFACILITY TYPE:
735
ADDRESS:268 W PAYSON STTELEPHONE:
(909) 967-6966
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 6DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Emma Banguguilan- Direct Care Professional (DSP)TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with caregiver Emma Banguguilan- Direct Care Professional (DSP) and explained the purpose for the visit. LPA conducted a tour of the physical plant with DSP, observed the food supplies, COVID-19 procedures, and reviewed client and staff files, and client's medications. The facility has an approved mitigation plan on file.

The facility is a one-story home located in a residential area. It is licensed to serve (6) developmentally disabled adults, ages 18-59, of which (2) may be ambulatory and (4) may be non-ambulatory. The home consists of a living room, kitchen, dining room, (3) resident bedrooms, (1) locked storage room, (2) client bathrooms, a shaded patio in the backyard with seating, and an attached garage. LPA observed all client bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. Bathrooms were observed to have a shower, toilet, and wash basin- all operational. The showers accommodate non-ambulatory residents and have the required grab-bars and non-skid mats. The water temperature was tested and measured between 107*F-114*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. A fire extinguisher was observed in the kitchen to have a current inspection and was fully charged. The first aid kit was inspected and had the required items, as well as a current first aid manual. All sharps were observed to be locked and inaccessible in a cabinet in the kitchen next to the stove. Cleaning supplies were locked and inaccessible, stored in a cabinet underneath the kitchen sink and in the garage. Extra linens were observed in the storage room and were in good condition. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. All equipment was operational and in good repair.


(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEMLY'S HOME CARE II
FACILITY NUMBER: 198600909
VISIT DATE: 12/05/2022
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LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the storage room inside the facility. Additional PPE was observed at the entrance of the facility- the central entry point for screening clients, staff, and visitors. PPE siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. All hand washing stations are fully stocked with liquid soap and paper towels. LPA was screened upon entry and was requested to wash hands.

All client files were reviewed and had updated emergency contact information and health screenings. (3) staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. All client medications were reviewed. They are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and Health and Safety Codes, no deficiencies were observed or cited during today's visit.

An exit interview was conducted with licensee and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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