336403859-3-3-2023-18-AS-YDEO-CPL3WD-20230303173635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403859
Report Date: 03/03/2023
Date Signed: 03/03/2023 05:37:36 PM

Document Has Been Signed on 03/03/2023 05:37 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GILS BOARD & CARE I		FACILITY NUMBER:	336403859
ADMINISTRATOR:	ELIZABETH GIL		FACILITY TYPE:	735
ADDRESS:	14080 ROCK PLACE		TELEPHONE:	(951) 780-3476
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92503
CAPACITY: 6		CENSUS: 3	DATE:	03/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Elizaberth Gil, Owner		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Yolanda Delgado and Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPAs was greeted by facility staff and granted entry. LPAs began inspection with introduction and visit purpose. Upon arrival LPAs learned that three (3) clients reside at this facility and there are currently one (1) caregiver present. LPA was later met by Monica Manness, Administrator. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA began review of resident records. Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/and Staffing- LPAs began review of employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification; expiration date 4/24/2023. Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. (Continued on page 2)

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GILS BOARD & CARE I	FACILITY NUMBER: 336403859
	VISIT DATE: 03/03/2023

NARRATIVE

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(Page 2 Continuation)

Physical Plant and Safety of Environment/Operational Requirements- LPAs toured the facility inside and outside. LPAs observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. This home does have a pool and is locked at all times with a 6 ft. rod iron fencing around the perimeter of the pool.

Medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I was reviewed. LPA observed that the facility maintains a separate log for each individuals monies. Money counted counted was accurately reflected on the ledger.

LPAs made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged this year, 01/2023 . The facility is conducting emergency disaster/fire drills quarterly; last done on 02/13/2023.

Based on the information received during this visit today in the areas reviewed, one (1) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809, LIC 809-D and Appeal rights reports was reviewed with and a copy provided to the facility representative.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/03/2023 05:37 PM - It Cannot Be Edited

Created By: Yolanda Delgado On 03/03/2023 at 05:22 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GILS BOARD & CARE I	FACILITY NUMBER: 336403859
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85095.5(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs Delgado and Banrasavong observation and interview, the licensee did not comply with the section cited above in Licensee did not have an Infection Control Plan developed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit an Infection Control Plan by fax to LPA Delgado by the POC.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jazmond D Harris

LICENSING EVALUATOR NAME:

Yolanda Delgado

LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

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