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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411359
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:19:15 PM

Document Has Been Signed on 02/09/2024 12:19 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:GALA HOMEFACILITY NUMBER:
366411359
ADMINISTRATOR:TOLENTINO, LILIAN MA.FACILITY TYPE:
735
ADDRESS:10986 GALA LANETELEPHONE:
(909) 902-9108
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 6CENSUS: 6DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Francis PastorfideTIME COMPLETED:
12:30 PM
NARRATIVE
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On 02/09/2023 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required comprehensive annual inspection to the facility. LPA Brown introduced self and stated the purpose of the visit. Administrator Francis Pastorfide was contacted and arrived during the visit.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed five (5) clients. There are no obstructions to indoor and outdoor passageway of the facility. The facility is maintained at a comfortable temperature. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, storage space, and sufficient lighting, however, LPA Brown observed missing one (1) night stand for Client #5 (C5) and Client #6 (C6) shared bedroom and two (2) night stands for Client #5 (C5) and Client #6 (C6) shared bedroom Also LPA Brown observed missing one (1) chair for Client #2 (C2) and Client #4 (C4) shared bedroom and missing one (1) chair for Client #5 (C5) and Client #6 (C6) shared bedroom. Deficiency will be issued. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 111 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book. Moreover, LPA Brown observed no night lights maintained in hallways and passages to nonprivate bathrooms. Deficiency will be issued.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GALA HOME
FACILITY NUMBER: 366411359
VISIT DATE: 02/09/2024
NARRATIVE
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Posters such as; the personal rights, CCLD complaint poster, emergency disaster plan were posted in a common area. Medications were kept in secure cabinets inaccessible to clients, however LPA Brown observed one (1) powerbolt manual chain saw hanging at the back area of the facility, not locked, accessible to clients in care. Deficiency will be issued. In addition, LPA Brown observed two (2) window screens and one (1) door screen in disrepair. Deficiency will be issued. Also, LPA Brown observed drawer in the laundry room in disrepair. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard. The outdoor pathway was free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed client files for Admission Agreements, Pre-placement Appraisal, Needs and Services Plans, Functional Capabilities, and Physician Report (LIC602). LPA Brown observed that Client #1 (C1), Client #3 (C3), and Client #5 (C5) do not have the Preplacement Appraisal, Needs and Services Plan and Functional Capabilities in their facility file. Deficiencies will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test result. Per LPA Brown records review, files reviewed are complete. LPA Brown reviewed C1, C3, and C5 P&I records and LPA Brown observed no issue. LPA Brown reviewed Client #2 (C2), C3 and Client #4 (C4) medications, LPA Brown observed no issue.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Administrator Francis Pastorfide.

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

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 15
Document Has Been Signed on 02/09/2024 12:19 PM - It Cannot Be Edited


Created By: Melody Brown On 02/09/2024 at 11:17 AM
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: GALA HOME
FACILITY NUMBER: 366411359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 locking the one (1) powerbolt manual chain saw hanging at the back area of the facility making it accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80087(g) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 02/09/2024 12:19 PM - It Cannot Be Edited


Created By: Melody Brown On 02/09/2024 at 11:17 AM
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: GALA HOME
FACILITY NUMBER: 366411359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 having a broken drawer in the laundry room in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to repair the broken drawer in the laundry room and submit proof to LPA Brown at Plan of Correction due date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 having two (2) window screens and one (1) door screen in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to repair the two (2) window screens and one (1) door screen and submit proof to LPA Brown at Plan of Correction (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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 02/09/2024 12:19 PM - It Cannot Be Edited


Created By: Melody Brown On 02/09/2024 at 11:17 AM
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: GALA HOME
FACILITY NUMBER: 366411359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

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 one (1) chair and one (1) nigt stand in Client #5 (C5) and Client #6 (C6) shared room and two (2) night stands and one (1) chair in Client #2 (C2) and Client #4 (C4) shared room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee provided one (1) chair and one (1) nigt stand in Client #5 (C5) and Client #6 (C6) shared room and two (2) night stands and one (1) chair in Client #2 (C2) and Client #4 (C4) shared room during the visit on 02/09/2024. Deficiency cleared.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

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 night lights maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to obtain or purchase night lights for the facility and submit proof to LPA Brown at Plan of Correction 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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 02/09/2024 12:19 PM - It Cannot Be Edited


Created By: Melody Brown On 02/09/2024 at 11:17 AM
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: GALA HOME
FACILITY NUMBER: 366411359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85077(a)
Personal Services
(a) Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing.

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 completing the required Needs and Services Plan for Client #1 (C1), Client #3 (C3) and Client #5 (C5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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LIcensee stated to complete and submit C1, C3 and C5 Needs and Services Plan to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

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 completing the required Functional Capabilities Assessment for Client #1 (C1), Client #3 (C3) and Client #5 (C5) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Licensee stated to complete and submit copies of C1, C3 and C5 Functional Capabilities Assessment 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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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