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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601493
Report Date: 07/13/2022
Date Signed: 07/14/2022 09:20:53 AM

Document Has Been Signed on 07/14/2022 09:20 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GMS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601493
ADMINISTRATOR:CHRISTOPHER SORTOFACILITY TYPE:
735
ADDRESS:18322 SUBIDO STREETTELEPHONE:
(626) 820-9387
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 5DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Blanca Nuno - DSP TIME COMPLETED:
03:00 PM
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Licensing Program Analysts(LPAs) Christine Wong and Ya Ting Yang conducted an annual required visit. LPA's met with DSP Stephanie Luna and DSP Blanca Nuno and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPAs observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility consists of living room, dining area, kitchen, three clients bedrooms, two bathrooms and a detached garage. All 3 clients bedrooms were toured. Each bedroom has two beds, two dressers, required bed linen and furniture and sufficient closet space and lighting. All two bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water temperature in the two bathrooms were tested between 121.9 and 123.2 which is beyond the required 105-120 degrees F. The refrigerator and the kitchen cabinet in the kitchen has sufficient two days perishable and seven days non perishable food. All the appliances in the kitchen working properly. The knives and sharp utensils are stored and locked in the kitchen drawer. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well. The back yard has a shaded area and sitting area for clients to utilize. All the chemicals are stored and locked under the sink and the garage cabinet which is inaccessible to clients. LPAs inspected the carbon monoxide detectors and smoke detectors and they are working well.

LPA's reviewed all 5 clients files to confirm emergency contact is updated. LPAs also reviewed staff files to confirm health screenings and fingerprint clearances and they are all updated. LPAs also reviewed 5 clients medication and they are all seemed accurate and updated.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in the common area and facility is disinfected every shift and restrooms have sufficient soap, paper towels, and signs and PPE supplies are sufficient for more than 30 days.


SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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: GMS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601493
VISIT DATE: 07/13/2022
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The following deficiencies are being cited on the attached LIC 809D page, California Code of Regulations, Title 22, Division 6, Chapter 1.

Exit interview conducted with Direct Support Professional, Blanca Nuno and a copy of this report is being provided and Appeal Rights were given.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2022 09:20 AM - It Cannot Be Edited


Created By: Christine Wong On 07/13/2022 at 02:22 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: GMS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
82088 Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA tested the hot water temperature in the two bathrooms and it was measured between 121.9 and 123.2 degrees
POC Due Date: 07/14/2022
Plan of Correction
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The administrator will ensure the hot water temperature measured between 105 and 120 degrees F. and the administrator will fix the hot water heater immediately and send the 7 days hot water log to LPA by 7/20/22
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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