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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601952
Report Date: 08/15/2022
Date Signed: 08/15/2022 01:25:05 PM

Document Has Been Signed on 08/15/2022 01:25 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:TOPAZ GEM HOME CAREFACILITY NUMBER:
198601952
ADMINISTRATOR:TORRES, GALILEOFACILITY TYPE:
735
ADDRESS:2996 ABBOTT STTELEPHONE:
(909) 908-8128
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:S-1TIME COMPLETED:
01:30 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 explained the purpose of today's visit.

This home consists of (4) bedroom, (2)bathrooms), living room, kitchen and dinning area.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed at the entrance of this facility and throughout the facility.
  • Per S-1, (5) clients have both COVID vaccines and have the booster. (1) Client/C-1 refuses to be vaccinated.
  • Per S-1, (7) staff have both COVID vaccines and have the booster.
  • Bathrooms have hand soap and paper towels. Hand washing signs were observed inside both bathrooms.
  • Hygiene items are stored inside the hallway closet.
  • PPE supplies observed. Additional PPE supplies are stored inside the garage.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. Additional food supply is stored inside the garage.
  • Staff responsible for direct care and supervision were wearing masks.
  • Clients were socially distanced according to local public health guidelines.
  • Medication reviewed for (6) Clients (Client #1 through Client #6).

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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