198603398-1-13-2024-28-AS-THEA-CZG2PZ-20240113163510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603398
Report Date: 01/13/2024
Date Signed: 01/13/2024 04:35:15 PM

Document Has Been Signed on 01/13/2024 04:35 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 II		FACILITY NUMBER:	198603398
ADMINISTRATOR:	MARTINEZ, SHERRY		FACILITY TYPE:	735
ADDRESS:	14771 RAGAN DRIVE		TELEPHONE:	(562) 946-9266
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	4	CENSUS: 4	DATE:	01/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	Ronaldo Uy - Caregiver		TIME COMPLETED:	04:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Ronaldo Uy (caregiver) and Paula Martinez (Registered Nurse-House Manager) who later assisted with the visit, the reason for the visit was explained. The facility is licensed to serve 4 non-ambulatory clients ages 18-59, of which 4 may be bedridden. Facility currently has 2 non-ambulatory clients and 2 bedridden clients serviced by Eastern Los Angeles Regional Center.

The facility is a single-story home located in a residential area in La Mirada, Ca. A tour of the facility includes: living room, dining room, kitchen, linen closet, 2 bathrooms, 3 bedrooms, 1 staff bedroom, 1 staff bathroom, detached garage with laundry, front yard, and back yard.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted in December 2023.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency. (Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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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Document Has Been Signed on 01/13/2024 04:35 PM - It Cannot Be Edited

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 II	FACILITY NUMBER: 198603398
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(12)(B)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff on staff roster (which were randomly selected for file review) were not associated with the facility during the time of visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2024
	Plan of Correction
1 2 3 4	Licensee shall associate S1 and S2 to facility and email proof of association to LPA by POC due date. NOTE: Staff not associated to the facility cannot work at the facility until they are associated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

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 II	FACILITY NUMBER: 198603398
	VISIT DATE: 01/13/2024

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Personnel Records-Training: Staff files are maintained in a locked staff office. LPA reviewed 5 staff files during today’s visit, files reviewed contained the following: current First Aid/CPR and sufficient on-going training. 2 staff were not associated to the facility details will be cited on the 809-D. Administrator Sherry Martinez (Sagasy) certificate expires on 1/30/25.
Client Rights-Information: Clients at the facility that require postural supports have proper doctors’ orders for supports. Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed throughout facility.
Client Records-Incident Reports: Client files are maintained in the locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Note that all clients at facility are on liquid diets, sufficient amount of liquid foods were observed.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a cabinet and are in their original containers. LPA reviewed 4 client’s medications and there were no issues observed.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, with the last drill conducted in December 2023.
Emergency Intervention: Clients at this facility do not need the use of restraints or the use de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. deficiencies observed during today’s visit are documented on the 809-D.

Exit interview was held and a copy of the report was provided to Administrator Sherry Martinez (Sagasy).

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2024

LIC809 (FAS) - (06/04)

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