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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880931
Report Date: 07/13/2022
Date Signed: 07/13/2022 02:49:37 PM

Document Has Been Signed on 07/13/2022 02:49 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
, 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:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Michael Nasal/Operations Manager/Administrator Cielita RaveloTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/13/2022 at 12:30 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Michael Nasal and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Operations ManagerAdministrator Cielita Ravelo was contacted and arrived during the visit. Administrator Nasal reported that they have five (5) clients at the facility. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Nasal and Operations Manager/Administrator Ravelo. Per documents review, Mitigation Plan was submitted 04/06/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, but no signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic. LPA Brown will be issuing a deficiency for this issue. LPA Brown toured the facility and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with Administrator Nasal and Operations Manager/Administrator Ravelo in relation to COVID-19 and Operations Manager/Administrator Ravelo reported to LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Operations Manager/Administrator Ravelo informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a deficiency during today's inspection for staff not being fit tested for N95 masks due to the facility recently had

**** Continuation in LIC809C ****

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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
, CA 92507
FACILITY NAME: GEMMA'S CARE CENTER
FACILITY NUMBER: 361880931
VISIT DATE: 07/13/2022
NARRATIVE
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covid-19 positive client and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.

LPA Brown observed all clients have been vaccinated and boosted and most staff are vaccinated and boosted and both clients and staff are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 07/13/2022 at 01:30 PM, LPA Brown observed Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6 have first, second and booster vaccination record maintained at the facility. However, Staff 1 has no Booster vaccination or exemption record maintained at the facility. LPA Brown will be issuing a deficiency for this item as this posespotential risk to clients in care.

An exit interview was conducted with Administrator Michael Nasal and Operations Manager/Administrator Cielita Ravelo and a copy of this report (LIC809), LIC 809D, and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/13/2022 02:49 PM - It Cannot Be Edited


Created By: Melody Brown On 07/13/2022 at 02:14 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
, CA 92507

FACILITY NAME: GEMMA'S CARE CENTER
FACILITY NUMBER: 361880931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having signs posted at the facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2022
Plan of Correction
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Licensee stated to submit proof of door signs sa facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic to LPA Brown at POC due date.
Type B
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision
(a)The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review, the licensee did not comply with the section cited above by not providing N95 respirator fit test to all the staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee stated to submit proof of N95 respirator fit test of all the staff to LPA Brown at POC due 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/13/2022 02:49 PM - It Cannot Be Edited


Created By: Melody Brown On 07/13/2022 at 02:24 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
, CA 92507

FACILITY NAME: GEMMA'S CARE CENTER
FACILITY NUMBER: 361880931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120279


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of persons in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the LIcensee did not verify workers vaccination, booster or exemption status or unvaccinated workers' test result as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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Licensee stated to submit proof of booster vaccination/exemption of Staff 1 to LPA Brown at POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


LIC809 (FAS) - (06/04)
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