<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602168
Report Date: 05/02/2024
Date Signed: 05/02/2024 01:24:15 PM

Document Has Been Signed on 05/02/2024 01:24 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:ELLER GEM CORPORATIONFACILITY NUMBER:
198602168
ADMINISTRATOR/
DIRECTOR:		CANONES, JUNELLEFACILITY TYPE:
735
ADDRESS:18469 ORKNEY STTELEPHONE:
(909) 767-1872
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 6DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Leonora CiriloTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Leonora Cirilo. House Manager Emma Banguguilan arrived shortly after who assisted with the visit. LPA explained the reason for the visit.

The physical plant was inspected along with medications, food supply, and resident and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center. There are five (5) ambulatory and one (1) non-ambulatory client who reside in the home. At the time of visit 3 clients were at the Day Program.


LPA toured the home and inspected three (3) client bedrooms, one (1) staff room two (2) bathrooms (one related to the staff room), kitchen, dining room, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. Laundry was observed in the garage. LPA observed laundry detergent locked in the cabinet and not accessible to clients. There is only one entrance being utilized at the facility. There is a fireplace located in the living room area which is covered / blocked with the office desk.
Client bedrooms were checked. Each bedroom has a smoke / carbon monoxide dedector, bed, linen, dresser, light, and sufficient closet space. Extra blankets, linens were observed in the closet located in the hallway. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured 143.5 degrees F. Cleaning supplies were observed unlocked in the bathroom which related to the staff room. Discontinued medications for the clients that should be destructed / returned to the pharmacy were observed unlocked in the staff room. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet inaccessible to clients.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 05/02/2024 01:24 PM - It Cannot Be Edited


Created By: Nune Margaryan On 05/02/2024 at 11:31 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: ELLER GEM CORPORATION
FACILITY NUMBER: 198602168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above. Cleaning supplies were observed unlocked in the bathroom which poses an immediate health, safety risk to persons in care which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 05/02/2024
Plan of Correction
1
2
3
4
Cleaning supplies were locked during the time of visit..
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the clients bathroom the hot water was measured at 143.5 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
1
2
3
4
The licensee will ensure that the hot water temperature is maintained between 105 degrees F - 120 degrees F as required and will submit a log for the next 24 hours showing the actual reading in the client bathroom.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/02/2024 01:24 PM - It Cannot Be Edited


Created By: Nune Margaryan On 05/02/2024 at 11:31 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: ELLER GEM CORPORATION
FACILITY NUMBER: 198602168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in. Discontinued medications for the clients that should be destructed / returned to the pharmacy were observed unlocked in the staff room which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
1
2
3
4
Room was locked immediatly.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELLER GEM CORPORATION
FACILITY NUMBER: 198602168
VISIT DATE: 05/02/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The carbon monoxide detectors were observed at the facility and working properly. Fire extinguishers observed in the kitchen and in the garage were fully charged and operational. LPA reviewed clients files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Deficiencies are being cited. See LIC 809D.



Exit interview was conducted with Emma Banguguilan. A copy of the report/appeal rights were issued.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4