<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880931
Report Date: 10/06/2021
Date Signed: 10/06/2021 11:33:35 AM

Document Has Been Signed on 10/06/2021 11:33 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GEMMA'S CARE CENTERFACILITY NUMBER:
361880931
ADMINISTRATOR:NASAL, MICHAELFACILITY TYPE:
735
ADDRESS:2950 ROAN STREETTELEPHONE:
(909) 218-7025
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 5DATE:
10/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Michael Nasal TIME COMPLETED:
11:45 AM
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 Analyst (LPA) Javier Prieto arrived to the facility to gather documentation related to an adult death of resident #1 (R1). LPA met with administrator Michael Nasal who explained on the morning of October 4th, 2021, R1 woke in the morning was alert during this time., R1 began to have hand tremors and was short of breath. Staff performed CPR and 911 was called. Paramedics arrived and continued to perform CPR. Approximately 0800 hours, paramedics pronounced R1 as expired,

LPA obtained the following documentation during today's visit: Medication Administration Record (MAR) log, Ontario PD contact information, Special incident report, staff CPR certificate, death report, resident CDER evaluation, P&I ledger, Client rights form, admission's agreement, client's physician's report, IRC IPP, weight log, recent prescribed medications, resident progress notes, medical report, resident property and centrally stored medication record.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 1