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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603397
Report Date: 06/01/2023
Date Signed: 06/02/2023 10:41:49 AM

Document Has Been Signed on 06/02/2023 10:41 AM - 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 IIIFACILITY NUMBER:
198603397
ADMINISTRATOR:MARTINEZ, PAULAFACILITY TYPE:
735
ADDRESS:15803 FOSTER ROADTELEPHONE:
(562) 352-0045
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 3DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Paula MartinezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. On today’s visit LPA met with Administrator Paula Martinez and the purpose of the visit was discussed.

LPA started the Care Tools. LPA conducted a tour of the facility along side Paula. LPA reviewed (3) client records, (4) staff files, and (3) client medications. Currently the facility has (3) clients of which are one (1) is ambulatory and two (2) are non-ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. The facility is part of a single story home located in a residential area and contains the following: living room, blocked fireplace, dining room, kitchen, locked storage cabinet for sharps, (4) clients rooms, (3) bathrooms of which (1) is a half bathroom with no shower. (1) Office room and (1) storage room. A back yard with shaded area and seating for use. An attached garage inaccessible to residents for storage; with washer and dryer. The residence is equipped with central air and heating. Front and back yard is in good condition at time of visit. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#4 are equipped with a bed for each client, a dresser, lamp, chair, overhead lightning. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in each client's bedrooms were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations. Care Tool was completed and based on Title 22 Regulations, no Deficiencies will be documented.

An exit interview was conducted and a copy of today's report was provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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