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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603395
Report Date: 01/12/2023
Date Signed: 01/12/2023 04:04:24 PM

Document Has Been Signed on 01/12/2023 04:04 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:GM HOME IFACILITY NUMBER:
198603395
ADMINISTRATOR:MARTINEZ, HENRYFACILITY TYPE:
735
ADDRESS:13111 BLUEFIELD AVETELEPHONE:
(562) 631-4157
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 5DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Susan Martinez, LicenseeTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Teresa Cruz and explained the purpose of the visit. Licensee Susan Martinez arrived shortly after. There are currently five (5 ambulatory developmentally disabled clients ages of 18 through 59 serviced by Eastern Los Angeles Regional Center (ELARC).The facility is a single story home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, kitchen, dining area, living room, outdoor patio, and detached garage. The last fire/emergency drill was conducted on 12/31/2022. Administrator certificate expires 6/21/2023.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Client bedroom #1 is designated as a COVID-19 isolation room if needed.
  • A posted Emergency Disaster Plan was observed.
  • Centrally stored medications/30-day supply of medications were observed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C).
  • Facility has a 30-day+ supply of Personal Protective Equipment (PPEs).
  • The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan (ICP).
  • Room #2 is presently being used as a live-in staff room. A deficiency was cited.
Exit interview was conducted with Licensee Susan Martinez. A copy of the report & appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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Document Has Been Signed on 01/12/2023 04:04 PM - It Cannot Be Edited


Created By: Noemi Galarza On 01/12/2023 at 03:44 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 I
FACILITY NUMBER: 198603395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(j)
PLAN OF OPERATION
(j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that bedroom #2 is being used as a live-in staff room, and not as a single occupancy client bedroom as indicated in the program design; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Licensee agreed to submit a written plan of correction. If Licensee would like to change the plan of operation it was advised to submit an Addendum and updated facility sketch.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023


LIC809 (FAS) - (06/04)
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