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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005778
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:33:22 PM

Document Has Been Signed on 02/05/2025 04:33 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:ANNISSA GEM CAREFACILITY NUMBER:
306005778
ADMINISTRATOR/
DIRECTOR:		LIMPIADO, GIDEONFACILITY TYPE:
740
ADDRESS:825 LILAC DRIVETELEPHONE:
(714) 203-1702
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Anthony "Tony" DeGuzmanTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Hanna Gough made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPAs were greeted and granted entry by Staff Anthony “Tony” DeGuzman and explained the purpose of the inspection.

During the inspection, LPAs and Staff DeGuzman conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with four resident bedrooms, three staff bedrooms, three bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. Resident beds were also observed to have half bed rails, however, a physician order for four of four residents could not be provided; a Deficiency was cited on today’s date. LPAs observed all windows were screened. The backyard has a shaded sitting area. LPAs observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 117.3-118.0 degrees Fahrenheit. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated January 9, 2025. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication cabinet was observed to be locked.

LPAs reviewed four resident files and two staff files. Four of four resident files did not contain an appraisal dated or signed in the last twelve months; a Deficiency was cited on today’s date. One of four resident files was observed to be missing an admission agreement and staff was unable to provide LPAs with a copy; a Deficiency was cited on today’s date. (Cont. LIC 9099-C)

Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840
DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 6
Document Has Been Signed on 02/05/2025 04:33 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/05/2025 at 03:46 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: ANNISSA GEM CARE
FACILITY NUMBER: 306005778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 two of two staff records, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff DeGuzman stated staff training will be completed and proof provided to LPA via email by POC date.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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 two of two staff files which poses a potential health and safety risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff DeGuzman stated staff training will be completed and proof provided to LPA via email by POC date.
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
TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME:Claudia Gutierrez
TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/05/2025 04:33 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/05/2025 at 03:46 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: ANNISSA GEM CARE
FACILITY NUMBER: 306005778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 three of four resident files which poses a potential health risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff DeGuzman stated an examination for communicable tuberculosis for residents will be completed and proof provided to LPA via email by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 four of four resident files, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff DeGuzman stated pre-admission appraisals will be updated in writing and proof provided to LPA via email by POC date.
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
TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME:Claudia Gutierrez
TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/05/2025 04:33 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/05/2025 at 03:46 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: ANNISSA GEM CARE
FACILITY NUMBER: 306005778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

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 of four resident files, which poses a potential personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff DeGuzman stated a copy of original signed and dated admission agreement will be provided to LPA via email by POC date.
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, the licensee did not comply with the section cited above in two of two staff files which poses a potential health and safety risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Staff DeGuzman stated staff training will be completed and proof provided to LPA via email by POC date.
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
TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME:Claudia Gutierrez
TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/05/2025 04:33 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/05/2025 at 03:46 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: ANNISSA GEM CARE
FACILITY NUMBER: 306005778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
87608(a)(3)
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in four of four resident records which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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2
3
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Staff DeGuzman stated a written order from a physician indicating the need for the postural supports will be obtained and proof providded to LPA via email
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
TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME:Claudia Gutierrez
TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: ANNISSA GEM CARE
FACILITY NUMBER: 306005778
VISIT DATE: 02/05/2025
NARRATIVE
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 Staff files did not contain any documentation for initial medication staff training or staff training conducted in the past year and staff was unable to provide LPAs with a copy of staff training conducted; a Deficiencies were cited on today’s date. LPAs interviewed residents and staff.

Based on the observations made during today’s inspection, 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 and appeal rights were 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: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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