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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601493
Report Date: 08/02/2024
Date Signed: 08/02/2024 10:54:00 AM

Document Has Been Signed on 08/02/2024 10:54 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:GMS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601493
ADMINISTRATOR/
DIRECTOR:		CHRISTOPHER SORTOFACILITY TYPE:
735
ADDRESS:18322 SUBIDO STREETTELEPHONE:
(626) 820-9387
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 4DATE:
08/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:01 AM
MET WITH:DSP Blanca NunoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with DSP Blanca Nuno at approximately 8:00 AM and explained the reason for the visit.

The home is licensed to serve up to six (6) non- ambulatory clients ages 18 - 59. The facility is a single-story house and located in a residential neighborhood area. The facility includes living room, dining area, kitchen, three (3) client bedrooms, two (2) client bathrooms and a detached garage.



LPA toured the facility and observed the following: Two (2) out of three (3) client bedroom has the required furniture and bedding. Bedroom #3 did not have chairs TV was given. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances are inaccessible to clients in a locked under sink. 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. Sharps are locked in cabinet in kitchen. 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. Bathroom #2 has a broken hot water handle deficiency cited. 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. The garage is clean and has a locked cabinet for cleaning supplies.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2024
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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Document Has Been Signed on 08/02/2024 10:54 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2024 at 10:09 AM
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: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above facility did not have an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator will email LPA Infection Control Plan.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 in one (1) out of two (2) bathrooms had broken hot water handle which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator will fix broken handle and send pictures via email to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/02/2024 10:54 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/02/2024 at 10:09 AM
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: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above S#1 and S#2 had expired CPR/First AID and was missing LIC 9052 Employee rights S#3 and S#4 was missing LIC 503 health screening and LIC 9052 Employee rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administartor will email all required documents to LPA.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above Administartor file was not at facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Administrator will email a copy of Administartor certificate and file to LPA.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: GMS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601493
VISIT DATE: 08/02/2024
NARRATIVE
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Four (4) Staff files were reviewed, and S#1 and S#2 were missing LIC 9052 Employee rights, and both had expired CPR/ First Aid, S#3, and S#4 both were missing LIC 503 with TB test and LIC 9052 Employee rights deficiency cited. Administrator did not have file at facility. Four (4) Client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Fire/earthquake drill was conducted on July 20th ,2024. No Infectious Control Plan was available deficiency cited. The medications are centrally stored and locked in a closet in living room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Blanca Nuno.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC809 (FAS) - (06/04)
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