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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603395
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:08:40 PM

Document Has Been Signed on 01/26/2024 02:08 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:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Susan Martinez, administratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arrival, LPA met with Susan Martinez, Administrator and discussed the purpose of today's visit. Facility is licensed to serve six (6) clients, non-ambulatory, ages from 18 to 59. Clients receive case management services provided by serviced by Eastern Los Angeles Regional Center (ELARC). Annual fees are current. Administrator certificate expires 6/21/25.

During the visit, the Care tool was used, interviews with staff/clients were conducted, a tour of the facility was conducted, food supply was reviewed, staff/clients files were reviewed and medications were reviewed.

The facility is a single story home located in a residential neighborhood. It consists of four (4) client bedrooms, two (2) bathrooms, kitchen, dining area, living room, outdoor patio, and detached garage. Common areas were observed for the ability to safely serve the needs of the clients. All outdoor and indoor passageways are free from obstruction. Client rooms were furnished with appropriate furniture for clients’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Hot water temperature was 108.5 degrees Fahrenheit which was within Title 22 Regulation guidelines.

Adequate linen and personal hygiene supplies were observed. Facility maintained a comfortable temperature for clients. A sufficient supply of perishable and non-perishable foods was observed. The back yard activity area was a shaded area with chairs and free of debris/ hazard. Smoke and carbon monoxide detectors were tested and operational. The last Fire/ Emergency Drill was conducted on 12/30/23. The fire extinguishers were fully charged. Medications were centrally stored, locked and the records were current. Hazardous items and sharp items were locked and inaccessible to clients.

No deficiencies were cited per California Code of Regulations, Title 22. An Exit conference was conducted with administrator. This report, LIC809s, were provided to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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