198601356-9-12-2023-28-AS-ALOZ-CVLPFJ-20230912111648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601356
Report Date: 09/12/2023
Date Signed: 09/12/2023 11:16:57 AM

Document Has Been Signed on 09/12/2023 11:16 AM - 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 CARE III		FACILITY NUMBER:	198601356
ADMINISTRATOR:	GEMMA RODRIGUEZ		FACILITY TYPE:	735
ADDRESS:	19002 HOLLYVALE DRIVE		TELEPHONE:	(626) 335-2151
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY: 6		CENSUS: 6	DATE:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Gemma Rodriguez		TIME COMPLETED:	11:28 AM

NARRATIVE

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Licensing Program Analyst ( LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with DSP Teresita Sapanghila and Administrator Gemma Rodriguez arrived a few minutes later and assisted with the visit. LPA explained the purpose of today's visit.

This is a one story adult residential facility (ARF) facility consisting of 3 client bedrooms 2.5 bathrooms, kitchen, dining room, activities room, laundry room, storage room, medication room and outdoor shaded activity area. This facility is licensed at a capacity of 6 clients and today's census was 6
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Physical Plant & Environment Safety: LPA observed 3 client bedrooms/bathrooms and closet/drawer space to accommodate each client comfortably was available. The facility is free of debris/hazards and the outdoor passageways and activity area are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 106.1 – 107.4 degrees F which is within required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in accessible to clients. The last Fire/Emergency Drill was conducted on 04/18/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed and recently inspected.

Operational Requirements: Facility is in compliance.

Staffing: There appears to be always sufficient staffing in the facility. Administrator Gemma Rodriguez certificate expires on 03/16/2024.

Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GEMLY'S HOME CARE III	FACILITY NUMBER: 198601356
	VISIT DATE: 09/12/2023

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Client Rights-Information: Client personal rights poster is posted in the facility.
Client Records-Incident Reports: Client files are kept in a secure location within the facility office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the kitchen area. All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 6 clients' medications, and only one issues were observed. PRN authorizations letters are missing for all 6 clients.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 2 Client interviews and 3 Staff interviews during today’s visit.

No deficiencies cited during today's visit. Technical advisor provided.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Gemma Rodriguez.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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