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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601493
Report Date: 08/31/2023
Date Signed: 09/14/2023 05:54:39 PM

Document Has Been Signed on 09/14/2023 05:54 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
GREATER LA AC/SC, 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: 4DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Blanca Nuno TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Blanca Nuno and explained the reason of the visit. The facility is approved for serve Developmentally Disabled Adults, cleared for 6 non-ambulatory. The facility is licensed as a 4I home vendored by San Gabriel Pomona Regional Center.

The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention.

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has an Infection Control Plan and COVID-19 mitigation plan in place.

2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, three clients bedrooms, two clients bathrooms and a detached garage. Each client bedroom has two beds, two drawers, night stand, chairs, required bed linen and sufficient lighting and closet space. The clients' bathrooms are clean, sanitary and in a workable condition. The hot water temperature tested in two bathrooms were 108.1 and 108.3 degrees F which are within Title 22 regulation. The appliances in the kitchen, living room and dining area are working probably. All the sharp knives and utensils are locked in the kitchen drawer. All the cleaning supplies and chemicals are locked under the sink. LPA inspected the smoke detectors and carbon monoxide detectors and they are interconnected and they are working probably. The facility has a land line telephone system for client to use it. The hallway night would turn on when it's at night, so clients can have access to the bathroom. (See LIC 809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GMS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601493
VISIT DATE: 08/31/2023
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All the extra personal hygiene products are stored in the hallway closet and the extra linen are stored in the hallway cabinet. The passageway, drive way and patio are free of obstruction.

3. Operational Requirements: The facility is licensed for six non-ambulatory. Currently all the clients in the facility are all ambulatory. The last fire/earthquake drill was conducted on 7/3/23. The clients can participate or attend the community activities if they want to or if there's any opportunity. The facility also has a shaded area in the patio with table and chairs for client to utilize as outdoor activity.

4. Staffing: The facility has sufficient staffing in the facility. The facility has two staff in AM Shift, two in the PM Shift and one in NOC shift. Due to staff files are not available for LPA reviewed, LPA was not able to review if staff has the facility planned emergency procedure training.

5. Personal Records-Training: Due to staff files are not available for LPA to be reviewed, LPA did not know if staff files has all the required training or documents in the staff personnel files.

6. Client's right-information: Currently the facility does not have any clients with postural support. Due to client's functional capability and clients do not know how to access with internet services.

7. Client's Records-Incident Reports: All the clients files are stored in the medication cabinet. LPA reviewed all four clients files and they all have the required documents including face sheet, admission agreement, Individual Program Plan (IPP), Updated physician report, TB test result and ambulatory status and medication list. All four (4) clients files do not have the functional capabilities assessment.

8. Food Service: Currently no client required modified diet. The facility has two days perishable and seven days Non perishable food supply. The food are stored probably in the facility and refrigerator. The refrigerator is maintained within the required temperature.

9. Health Related Services: The clients medication are stored and locked in the medication closet near the entrance way. LPA inspected all four clients' medication and they are seemed accurate and up-to-dated.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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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: GMS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601493
VISIT DATE: 08/31/2023
NARRATIVE
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10. Incidental Medical Services: Currently no client in the facility has any prohibited health condition or restricted health condition.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D). The last fire/disaster drill was conducted on 7/3/23 and the facility has two alternative temporary shelter location.

12. Emergency Intervention: The facility staff does not use any restraints or CPI on clients.

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 DSP Blanca Nuno and a copy of this report is being provided and Appeal Rights were given.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/14/2023 05:54 PM - It Cannot Be Edited


Created By: Christine Wong On 08/31/2023 at 02:46 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based onrecord review, LPA observed the all four (4) clients' files do not have the written functional capabilities assessment (LIC9172) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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The administrator will complete all four clients' functional capabilities assessment form (LIC9172) and send to LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/14/2023 05:54 PM - It Cannot Be Edited


Created By: Christine Wong On 08/31/2023 at 03:05 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: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)

80066 Personnel Records
(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA was not able to review staff files as staff files were not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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The facility administrator will ensure all pesonnel records shall be maintained at the facility site and read the Title 22 regulation and send the plan to LPA about how to meet the regulation by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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