<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600909
Report Date: 01/22/2024
Date Signed: 01/22/2024 05:22:12 PM

Document Has Been Signed on 01/22/2024 05:22 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:
(626) 812-9414
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 6DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Emmaruth BanguguilanTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Emmaruth Banguguilan. Assistant Administrator Ulysis Rodriguez arrived shortly after who assisted with the visit. LPA explained the reason for the visit.

The physical plant was inspected along with COVID-19 procedures, medications, food supply, and clients and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 of which (2) may be ambulatory and (4) may be non-ambulatory. There are currently 6 clients residing at the home and receive services from San Gabriel / Pomona regional Center. This is a single-story home located in a residential neighborhood and consists of the following: 3 clients bedrooms, 1 storage room (locked), 2 clients bathroom, living room, dining room, kitchen, attached garage, backyard and front yard. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Laundry is in the garage. Passageways and exits are free of obstruction. Client bedrooms and bathroom were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. Bathrooms are clean and have the required hygiene items. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. Extra linens, blankets, towels, and personal hygiene supplies were observed. There is a fireplace located in the living room area which covered by a screen. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. All sharps are locked in the kitchen cabinet and are inaccessible to clients. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the kitchen and in the garage.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
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 2
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: 01/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Fire extinguisher observed in the kitchen fully charged. Carbon monoxide/smoke detectors in the hallway and in the client rooms are operational. Centrally stored medications are stored in a locked cabinet in the kitchen. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided to staff Emmaruth Banguguilan.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2