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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601663
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:17:44 PM

Document Has Been Signed on 03/16/2022 02:17 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAPPHIRE GEM HOME CAREFACILITY NUMBER:
198601663
ADMINISTRATOR:SAMONTE, MICHELLE TORRESFACILITY TYPE:
735
ADDRESS:326 E LA VERNE AVETELEPHONE:
(909) 623-0728
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:S-1 and S-3TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and discussed the purpose of today's visit.

This home consists of (4) private rooms, (2) restrooms, kitchen, dinning area, living room and detached garage. All clients receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected: .
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed. COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • PPE supplies observed. Additional supplies observed inside the hallway closet and detached garage.
  • Hygiene supplies observed (stored/locked inside the hallway closet).
  • Restrooms have hand soap, hand sanitizer and paper towels.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication reviewed for (4) Clients (C-1 through C-4). Medication is locked inside the medication cabinet located in the living room.
  • Per S-1, C-1 through C-4 are vaccinated and have their booster. Clients were be socially distanced according to local public health guidelines.
  • Per S-1, all staff are vaccinated and have their booster except for S-2. However, S-2 undergoes weekly COVID-19 testing.
  • Staff responsible for direct care and supervision will wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-3.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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