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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004236
Report Date: 10/27/2022
Date Signed: 10/31/2022 08:43:32 AM

Document Has Been Signed on 10/31/2022 08:43 AM - 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:G.M. HOME IVFACILITY NUMBER:
306004236
ADMINISTRATOR:SUSAN GO MARTINEZFACILITY TYPE:
735
ADDRESS:10143 SHADYPOINT DRIVETELEPHONE:
(562) 631-4157
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 4CENSUS: 4DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Susana MartinezTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator Susana Martinez and the purpose of the visit was discussed. .

As a part of the inspection, LPA used the inspection tool, reviewed (4) client records, (4) staff files, and (4) client medications. Currently the facility has (4) clients which are ambulatory. The facility is vendorized through Eastern Los Angeles Regional Center. Facility is a one story family home with four (4) bedrooms, two (2) full bathrooms, (1) half bathroom, living room, dining area, kitchen, central air and heating, laundry room, a shaded area located in the backyard. an attached two car garage inaccessible to clients. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#4 are equipped with a bed for each client, a dresser, lamp, chair, overhead lightning. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in each client's bedrooms were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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