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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000549
Report Date: 04/18/2022
Date Signed: 04/18/2022 01:06:49 PM


Document Has Been Signed on 04/18/2022 01:06 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GEM'S VILLE HOME CAREFACILITY NUMBER:
306000549
ADMINISTRATOR:ROLANDO F. NUQUIFACILITY TYPE:
740
ADDRESS:819 WEST MAXZIM AVENUETELEPHONE:
(714) 855-8596
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:5CENSUS: 1DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jasmin NuquiTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by Administrator (AD) Jasmin Nuqui and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

This is a single-story house with five bedrooms, and two bathrooms. During the inspection LPA observed two staff and one resident in care. Resident was observed resting in respective room. LPA observed the facility does not have a 30-day supply of PPE on hand; a Technical Advisory was given on this date. Upon record review LPA noted that emergency contact information was incomplete, and physician report stated resident cannot administer their own medication, two deficiencies were given on this date.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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 04/18/2022 01:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GEM'S VILLE HOME CARE
FACILITY NUMBER: 306000549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of one resident files which poses a potential health and safety risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Facility needs to update forms and email LPA Claudia Gutierrez copies of the forms completed by 04/22/2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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