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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006060
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:35:51 PM


Document Has Been Signed on 01/11/2024 02:35 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:G & G HOME CARE INC.FACILITY NUMBER:
306006060
ADMINISTRATOR:DIZON, GERTRUDEFACILITY TYPE:
740
ADDRESS:24952 VIA MARFILTELEPHONE:
(626) 202-7651
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:6CENSUS: 5DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Maria Josefa AlorroTIME COMPLETED:
11:53 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to G & G Home Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Maria Alorra. Facility is licensed for 6 non-ambulatory residents, two of which may be bedridden. Facility has an approved hospice waiver for 2 residents and the home currently has 5 residents. There is 1 resident on hospice during today's visit. Facility appears to be clean, safe, and sanitary. Gina Dizon has an Administrator Certificate expiring on 11/16/2024. Administrator Gina Dizon arrived during the visit.

LPA Lyman along with Caregiver Maria Alorro toured the facility at 8:35 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of six resident bedrooms, one resident bathroom, one office area, two shared hall bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed three residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 109 and 120 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. The entry door into the garage is alarmed.. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 11/23/2023. Facility provides activities in the form of games and exercise. CONT ON LIC 809C DATED 1/11/2023.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: G & G HOME CARE INC.
FACILITY NUMBER: 306006060
VISIT DATE: 01/11/2024
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At 9:30 AM, LPA reviewed five resident files and two staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 10:15 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.

Based on the observations made during today's visit, no deficiencies are being cited.
Exit interview conducted and a copy of this report was given at time of visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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