306004236-10-6-2023-28-AS-JVIS-CWCUYM-20231006160006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004236
Report Date: 10/05/2023
Date Signed: 10/06/2023 04:00:25 PM

Document Has Been Signed on 10/06/2023 04:00 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:	G.M. HOME IV		FACILITY NUMBER:	306004236
ADMINISTRATOR:	SUSAN GO MARTINEZ		FACILITY TYPE:	735
ADDRESS:	10143 SHADYPOINT DRIVE		TELEPHONE:	(562) 631-4157
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY: 4		CENSUS: 4	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Facility Registered Nurse Paula Martinez		TIME COMPLETED:	12:20 PM

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Facility Registered Nurse Paula Martinez and the purpose of the visit was discussed.
The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
A fire clearance for four clients of which (4) may be non ambulatory; 0 may be bedridden.

Physical Plant/Environment Safety:

The facility does not have Dementia clients. Facility is a 1-story residential home with 4 client bedrooms, 2 1/2 bathrooms, activity rooms, dining room, kitchen, office, and a front and backyard.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
On 9/8/23, The sprinkler system, and alarms were inspected. Fire extinguishers Observed
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Personnel Records/Staff Training:

Administrator certification accurate
Staff have criminal background clearance and training.
Five (5) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed.

Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 IV	FACILITY NUMBER: 306004236
	VISIT DATE: 10/05/2023

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Staffing:

A total of 12 staff members provide care and supervision to the clients.

Resident Records/Incident Reports:

A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.
Complaint poster and Personal rights were observed posted.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar was reviewed

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:

Four Client (4) centrally stored resident medications were reviewed.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.

Residents with Special Health Needs:

There are currently (4) Clients and none are on Hospice or Home Health
No half bed rails for mobility assistance were observed in rooms.
Individual Service Plans and Appraisals are on file.
No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, NO deficiencies were cited. 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: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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