198603394-3-10-2025-28-AS-DKOI-DEG2LP-20250304162951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603394
Report Date: 03/04/2025
Date Signed: 03/10/2025 04:56:45 PM

Document Has Been Signed on 03/10/2025 04:56 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GM HOME MEYER		FACILITY NUMBER:	198603394
ADMINISTRATOR/ DIRECTOR:	MARTINEZ, SUSAN		FACILITY TYPE:	735
ADDRESS:	13118 MEYER ROAD		TELEPHONE:	(562) 631-4157
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY: 4		CENSUS: 2	DATE:	03/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Susan Martinez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 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) Daniel Konishi conducted an unannounced visit at the facility for the purpose of conducting the required annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Konishi met with Administrator, Susan Martinez and explained the purpose for the visit. This home is licensed to serve adults range ages 18 through 59 approved for four (4) bedridden and vendored by East Los Angeles Regional Center. There were two (2) clients in care during the time of this visit. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. Infection Control: The facility has an infection control plan in place and the 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. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap, and paper towels. Facility Administrator is adhering to infection control requirements. Operational Requirements: Facility Administrator is adhering to operational requirements. Facility ensures the clients are given the opportunity to attend and participate in community activities.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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 03/10/2025 04:56 PM - It Cannot Be Edited

Created By: Daniel Konishi On 03/04/2025 at 04:15 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: GM HOME MEYER	FACILITY NUMBER: 198603394
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review, Client #1 (C1) and (C2’s) Admission Agreement was not in file during the visit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2025
	Plan of Correction
1 2 3 4	Administrator will send a copy of the Client #1 (C1) and (C2’s) Admission Agreement to the LPA by the POC due date. daniel.konishi@dss.ca.gov

Type B

Section Cited

HSC

1565(a)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, the facility did not have an Emergency Disaster Plan readily accessible nor in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2025
	Plan of Correction
1 2 3 4	Admkinistrator will send a copy of the Emergnency Disaster Plan to the LPA by the POC due date. daniel.konishi@dss.ca.gov

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:

David Sicairos

LICENSING EVALUATOR NAME:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GM HOME MEYER	FACILITY NUMBER: 198603394
	VISIT DATE: 03/04/2025

NARRATIVE

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Physical Plant & Environment Safety: The facility is a single-story home located in a residential neighborhood and consists of four (4) client bedrooms, 3 bathrooms, living room, kitchen, activity area, dining area, office area, and garage. All client rooms were inspected and LPA observed client beds and the bedding for each bed were in good condition, adequate lighting provided, storage for client personal belongings was observed for each client. Each client bedrooms include all required furniture: a bed, chair, lamps, lift systems, and sufficient lighting and closet space. The client’s bathroom is clean, sanitary and in a good working condition. Walls and floors were in good repair. Clean towels and new bed linens are in the hallway closet. Bathroom is clean and operational. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to clients. Grab bars observed in the bathroom. Bathroom water temperature was tested as follows: water temperature tested between 108.1 degrees F and 108.6 degrees F which is within the required 105-120 degrees F. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. All sharps and knives are locked in the med cart and inaccessible to clients. Cleaning supplies are locked in the cabinet in the garage and inaccessible to clients. Carbon monoxide detectors were tested and in working condition. Fire extinguishers are in the dining room and is fully charged and last inspected on 02/10/2025.

Staffing: There is sufficient staffing at the facility. 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, and Staff #1 (S1) to Staff #4 (S4). Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff files reviewed had criminal record clearances and were associated to the facility. Staff have their Health Screening and Tuberculosis Screening, Employee Rights, Personnel Record on file. Administrator Certificate expires on 06/21/2025. Administrator has required HIV & TB training on file.

Client Rights-Information: Facility does not have any clients requiring postural supports. Client personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services to all clients.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GM HOME MEYER	FACILITY NUMBER: 198603394
	VISIT DATE: 03/04/2025

NARRATIVE

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Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C1) through Client #2 (C2). Client files are maintained at the facility and have the following documents in their files - Face sheet, Emergency and Identification Information form, Physician's Report (including T.B and Ambulatory Status), Immunization records, Client Medication Destruction Record, Individual Program Plan (IPP), Functional Capabilities Assessment, Client Personal Property, and Clients Personal Rights. However, based on record review, Client #1 (C1) and (C2’s) Admission Agreement was not in file during the visit.

Food Service: The facility has sufficient food supplies and client formula. The non-perishable 7-day food supply is stored in the cabinet. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. There are clients that have restricted health conditions.

Health Related Services The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C2. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items. Facility staff provide transportation to medical and dental appointments.

Incidental Medical Services: Based on record review and staff interview, there are clients under restricted health conditions and proper staff training for restricted health conditions are in file.

Disaster Preparedness: Emergency Fire Drill was conducted on 3/3/2025. However, based on record review and observation, the facility did not have an Emergency Disaster Plan readily accessible nor in file.

Emergency Intervention: The facility does not use any restraint on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to S4.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

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