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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603395
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:38:43 PM

Document Has Been Signed on 01/07/2025 03:38 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GM HOME IFACILITY NUMBER:
198603395
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, HENRYFACILITY TYPE:
735
ADDRESS:13111 BLUEFIELD AVETELEPHONE:
(562) 631-4157
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:47 PM
MET WITH:Susan MartinezTIME VISIT/
INSPECTION COMPLETED:
03:53 PM
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Susan Martinez, administrator for the facility, arrived shortly thereafter. There are five (5) ambulatory clients residing in the facility.

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 and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a completed infection control plan.



Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of six (6) non-ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of two (2) shared and two (2) single client bedrooms, a kitchen, a dining room, a detached garage the contains the facility’s washer and dryer machines, and two (2) client restrooms of which Restroom #1 which had a hot water temperature reading of 105.0 Degrees Fahrenheit, and Restroom #2 had a hot water temperature of 104.9 Degrees Fahrenheit. Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients. A shaded outdoor area was available for clients in the backyard of the facility.


· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system is operational. The facility has two (2) fully charged fire extinguishers that are kept throughout the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GM HOME I
FACILITY NUMBER: 198603395
VISIT DATE: 01/07/2025
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Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) non-ambulatory clients between the ages of 18 – 59.


· Care and supervision to meet the clients’ needs was observed.

Staffing:

· A total of seven (7) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires in 6/21/2025.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.

Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GM HOME I
FACILITY NUMBER: 198603395
VISIT DATE: 01/07/2025
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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.


· None of the clients of the facility have a restricted health condition or restricted health care plan.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.


· Five (5) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan.


· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.


· The last documented disaster drill was documented on 10/7/2024.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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