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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 01:11:35 PM
Document Has Been Signed on
04/18/2022 01:11 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 CARE
FACILITY NUMBER:
306000549
ADMINISTRATOR:
ROLANDO F. NUQUI
FACILITY TYPE:
740
ADDRESS:
819 WEST MAXZIM AVENUE
TELEPHONE:
(714) 855-8596
CITY:
FULLERTON
STATE:
CA
ZIP CODE:
92832
CAPACITY:
5
CENSUS:
1
DATE:
04/18/2022
TYPE OF VISIT:
Case Management - Deficiencies
UNANNOUNCED
TIME BEGAN:
11:30 AM
MET WITH:
Jamin Nuqui
TIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez conducting this inspection for the purpose of a deficiency.
SUPERVISORS NAME
:
Armando J Lucero
LICENSING EVALUATOR NAME
:
Claudia Gutierrez
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)
Page:
1
of
2
Document Has Been Signed on
04/18/2022 01:11 PM
- It Cannot Be Edited
Created By:
Claudia Gutierrez
On
04/18/2022
at
12:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2022
Section Cited
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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(4) The licensee shall assist residents with self-administered medications as needed.
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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 Lucero
LICENSING EVALUATOR NAME:
Claudia Gutierrez
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)
Page:
2
of
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