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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601356
Report Date: 07/13/2024
Date Signed: 07/13/2024 10:04:10 AM


Document Has Been Signed on 07/13/2024 10:04 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
MONTEREY PARK ASC, 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:
07/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:DSP Yolanda CiriloTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met DSP worker Yolanda Cirilo at approximately 8:00 AM and explained reason for visit. Administrator Gemma Rodriguez arrived shortly.

Facility is licensed to serve (6) developmentally disabled adults, ages 18-59. Four can be non-ambulatory. This single-story home contains Three (3) bedrooms, one (1) activity room, three (3) bathrooms, a living room, kitchen, dining area, laundry area, enclosed patio/activity area, backyard, and garage.

LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the dining room and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in kitchen. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage in garage as well as within other locked cupboards in kitchen. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer in garage with more food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

Three (3) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Five (5) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in March of 2024. Infectious control plan was reviewed. One (1) staff and (1) client was interviewed. Five (5) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GEMLY'S HOME CARE III
FACILITY NUMBER: 198601356
VISIT DATE: 07/13/2024
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No deficiency was observed during today’s visit. Exit interview was conducted with Administrator Rodriguez and a copy of report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Christian GutierrezTELEPHONE: 323-981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3