<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603398
Report Date: 03/20/2023
Date Signed: 03/20/2023 02:59:45 PM

Document Has Been Signed on 03/20/2023 02:59 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 IIFACILITY NUMBER:
198603398
ADMINISTRATOR:MARTINEZ, SHERRYFACILITY TYPE:
735
ADDRESS:14771 RAGAN DRIVETELEPHONE:
(562) 946-9266
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 4DATE:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee Susan Martinez TIME COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. Upon visit LPA met with staff Danilo Navarro and discussed the purpose of the visit. Licensee Susan Martinez arrived shortly after.

LPA started the Care Tools. LPA conducted a tour of the facility along side Susan. Facility is a one story family home with three (3) client bedrooms, one (1) staff room, Three (3) bathrooms, living room, kitchen, dining area, a den, an attached garage for laundry and storage, and a backyard with shaded area for clients. There are currently four (4) clients living in the facility.

Physical Plant: Outdoor and indoor passageways are free of obstruction. Bathrooms were clean and operational with non-skid mats, water temperature in compliance. Smoke/carbon monoxide detectors were tested and operational. The last fire drill was conducted on 3/1/23. Fire extinguisher observed. Required postings observed. Sufficient supply of extra linen, towels and personal hygiene supplies observed. Central Air and Heating with temperature comfortable. Washer/Dryer appliances observed and operational. Front and back yard is in good condition, shaded area is provided. All clients on g-tube feeding, sufficient g-tube meals observed emergency supplied observed. Toxins and sharps locked and inaccessible to clients. BEDROOMS: Bedrooms #1-#3 had required furnishing. All client beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket, and bedrails ordered by physician.
MEDICATION: Medications are stored, locked and inaccessible to clients. LPA reviewed four (4) client medications RECORD REVIEW: Facility Administrator Certificate for Susan Martinez is active. Four (4) Staff Files reviewed. Four (4) client filed reviewed

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: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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 1