198603397-3-22-2024-28-AS-EZAA-D3LVF8-20240322162331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603397
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:24:04 PM

Document Has Been Signed on 03/22/2024 04:24 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 III		FACILITY NUMBER:	198603397
ADMINISTRATOR:	MARTINEZ, PAULA		FACILITY TYPE:	735
ADDRESS:	15803 FOSTER ROAD		TELEPHONE:	(562) 352-0045
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 4		CENSUS: 2	DATE:	03/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Patricio Ramirez - Caregiver		TIME COMPLETED:	04:40 PM

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Licensing Program Analysts (LPAs) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Patricio Ramirez, Direct Support Staff (DSP) of the facility, and was granted entrance. Administrator Susan Martinez arrived shortly thereafter. There is one (1) ambulatory and one (1) non-ambulatory client residing within the home.

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 had 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 four (4) clients between the ages of eighteen (18) through fifty-nine (59), all of which may be non-ambulatory and bedridden. It consists of four (4) client bedrooms, a kitchen, a dining room, living room, and two client bathroom of which Restroom #1 (R1) had a hot water temperature reading measured at 108.8 Degrees F, and Restroom #2 (R2) had a hot water temperature reading at 109.2 Degrees F, a shaded outdoor patio area in the backyard, and a detached garage which houses the washer and dryer machines along with the emergency food supplies for the facility. Knives are kept locked in a closet in the kitchen of the facility, and the chemicals and cleaning supplies are kept locked in the garage of the facility.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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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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 III	FACILITY NUMBER: 198603397
	VISIT DATE: 03/22/2024

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational. The facility has two (2) fully charged fire extinguishers that are kept in the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) ambulatory clients between the ages of 18 – 59, all of which may be non-ambulatory and bed-bound.

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

· A total of ten (10) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires on 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:

· Two (2) 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: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GM HOME III	FACILITY NUMBER: 198603397
	VISIT DATE: 03/22/2024

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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.

· The facility has a restricted health care plan in place for one (1) of the clients, because they require feeding through Gastronomy Tube.

Health Related Services:

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

· Two (2) 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, and COVID-19 vaccination cards on file.

· 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 3/2/2024

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 was provided to the administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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