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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601356
Report Date: 08/03/2022
Date Signed: 08/03/2022 02:49:00 PM

Document Has Been Signed on 08/03/2022 02:49 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 IIIFACILITY NUMBER:
198601356
ADMINISTRATOR:GEMMA RODRIGUEZFACILITY TYPE:
735
ADDRESS:19002 HOLLYVALE DRIVETELEPHONE:
(626) 335-2151
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Staff #1 DSPTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst's(LPA) Vasallo and Yang conducted an annual required visit. LPA's met with Staff #1 (S1) and explained the reason for the visit. Administrator was called and notified of the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the physical plant, COVID-19 procedures, reviewed clients' medications and records, staff records and observed the food supply. The facility cares for intellectually disabled adults and is vendorized by San Gabriel/Pomona Regional Center.

All client bedrooms were toured. Bedrooms have the required bed, bedframe, linen, dresser, light, and closet space. Client bathrooms were toured and the hot water was 105.8 degrees which is within the required 105 - 120 degrees. The hallway bathroom has tile missing from the sink. According to staff, the tile broke off. There were no toxic chemicals accessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is a second refrigerator in the garage with additional food. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are no cameras inside the facility. There is a screening station at the entrance of the facility to screen visitors. Staff document client and staff temperatures and symptoms daily.

All 5 client files were reviewed to confirm emergency contacts and physician's reports. 4 staff files were reviewed to confirm health screenings, training and fingerprint clearances. All files were complete. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed is documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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Document Has Been Signed on 08/03/2022 02:49 PM - It Cannot Be Edited


Created By: Tony Vasallo On 08/03/2022 at 02:33 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 III
FACILITY NUMBER: 198601356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

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 which poses a potential health, safety or personal rights risk to persons in care. Hallway bathroom had tile missing from sink. According to staff, the tile broke off.
POC Due Date: 08/17/2022
Plan of Correction
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Licensee will repair the bathroom sink. Proof of repair will be submitted by 8/17/22.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022


LIC809 (FAS) - (06/04)
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