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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601663
Report Date: 03/13/2023
Date Signed: 03/13/2023 02:49:56 PM

Document Has Been Signed on 03/13/2023 02:49 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: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:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH: Nora Rodriguez/S-1 and Divina Sanchez/S-2TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Nora Rodriguez/S-1 and Divina Sanchez/S-2. LPA explained the purpose of today's visit.

The facility is licensed for (6) ambulatory clients ages 18 through 59. The fire clearance is approved for (6) ambulatory clients. All clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: The fire clearance is approved for (6) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted on 02/03/2023.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAPPHIRE GEM HOME CARE
FACILITY NUMBER: 198601663
VISIT DATE: 03/13/2023
NARRATIVE
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Physical Plant & Environment Safety: This facility consists of (4) bedrooms (2) bathrooms (1 of which is located in the hallway and 1 of which is located inside room #3 bedroom), living room, kitchen, dining area, and detached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last services on 01/05/2023. Carbon monoxide tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 113* in the kitchen, 114.7* in the bathroom (hallway) and 115.5* bathroom (located inside room #3).

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Michelle T Samonte expires on 11/24/2023 and HIV Training Certificate is dated 07/17/2021. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, S-1 and S-2. S-2’s CPR/first aid training expired on 01/11/2023. Staff have sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance. Deficiency noted and will be cited on LIC 809D.

Client Rights-Information: Client personal rights are posted. Per S-2, facility provides internet services to all clients and have access to the facility phone. Per S-2, (3) out of (4) clients have their own personal cell phones. Per S-2, (2) out of (4) clients have their own tablet.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-4. Client files are maintained at the facility. Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed. However, C-4's Admission Agreement and Functional Capability Assessment were missing. Deficiencies noted and will be cited on LIC 809D.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAPPHIRE GEM HOME CARE
FACILITY NUMBER: 198601663
VISIT DATE: 03/13/2023
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Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside the laundry closet). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C-1 through C-3. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per S-2, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility does not have a complete Emergency Disaster and Mass Casualty Plan. LPA provided a copy of the Care Tool standards covering Health and Safety Code 1565 and California Code of Regulation 80023 to S-2. Deficiency noted and will be cited on LIC 809D.

Emergency Intervention : Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to Divina Sanchez.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/13/2023 02:49 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 03/13/2023 at 12:53 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: SAPPHIRE GEM HOME CARE
FACILITY NUMBER: 198601663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in (1) out of (3) staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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This standard is not met as evidence by: S-2's First Aid Training Certificate expired on 01/11/2023. Facility Administrator to submit proof of First Aid training enrollment for S-2 to LPA Irra by POC due date of 03/17/2023.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

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 in (1) out of (4) client files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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This standard is not met as evidence by, C-4 is missing the Adminission Agreement. Per S-2, C-4 was admitted to this facility on 02/24/2023. Administrator to submit a copy of C-4's Admission Agreement to LPA Irra by POC due date of 03/17/2023.

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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/13/2023 02:49 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 03/13/2023 at 12:53 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: SAPPHIRE GEM HOME CARE
FACILITY NUMBER: 198601663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2023

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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Based on record review, the licensee did not comply with the section cited above in (1) out of (4) client files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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This standard is not met as evidence by, C-4 is missing the Functional Assessment. Plan of Correction: Administrator to submit a copy of C-4's Functional Assessment to LPA Irra by POC due date of 03/17/2023.
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record view, the licensee did not comply with the section cited above as the facility did not have a complete disaster and mass casualty plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
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This standard is not met at evidence by: Facility does not have a complete Disaster and Mass Casualty Plan. LPA provided a copy of the Care Tool standards covering Health and Safety Code 1565 and California Code of Regulation 80023 to S-2. Facility Administrator to complete and submit these plans to LPA Irra by POC due date of 03/27/2023.
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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023


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