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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700557
Report Date: 08/03/2022
Date Signed: 08/05/2022 02:51:36 PM


Document Has Been Signed on 08/05/2022 02:51 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GELZHEN GUEST HOME LLCFACILITY NUMBER:
392700557
ADMINISTRATOR:LAJA, JOYFACILITY TYPE:
740
ADDRESS:119 N LINCOLN AVETELEPHONE:
(209) 239-5500
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:15CENSUS: 7DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Joy LajaTIME COMPLETED:
03:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 08/03/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility kitchen staff person, Apol Santos, and caregiver Nick Carbonell. Mr. Carbonell stated that there was also another caregiver present named Adrianna Sanchez-Garcia. He informed this LPA that they have only been employed for one month here so far.
This LPA requested that the caregiver go ahead and contact the facility designated Administrator, Joy Laja, to inform her that CCL was present at this time for an annual visit. The facility designated Administrator arrived later to this facility while this LPA was conducting the annual review.
Current census was 7 residents.
There were hospice residents in care at this time. In addition, there were residents who required assistance with glucose monitoring and diabetes related tasks everyday.
Tour of this facility was conducted.
Living room, dining room, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage units were reviewed to make sure that they were functional and in good repair at all times. A review of the food supply was conducted for adequate 2-day perishable and 7-day nonperishable quantities at all times. An additional food storage unit was used and placed in the garage area.
Garage area was toured. The car of the facility designated Administrator was placed in there at this time as she had just arrived while this LPA was reviewing the garage area.
A tour of the facility resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GELZHEN GUEST HOME LLC
FACILITY NUMBER: 392700557
VISIT DATE: 08/03/2022
NARRATIVE
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Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Nor Cal Fire, and observed to be in compliance at this time.
Linen closet was observed to contain a sufficient supply of blankets, towels, and linens sufficient to meet the needs of the residents at this time.
First aid kit, located in the kitchen area, was reviewed and observed to contain all of the required components at this time.
Medication cart, located in the kitchen area, was reviewed.
Brief interview was conducted with the facility designated Administrator Joy Lajas.
Tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and emergency exits was conducted.
There was a total of (4) storage units/areas being used at this time to house old mattresses and furniture for this facility at this time.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/05/2022 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GELZHEN GUEST HOME LLC
FACILITY NUMBER: 392700557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathroom faucets delivering hot water which measured at 122.1 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Facility designated Administrator will turn down the hot water heater and measure the hot water for the next 24 hours and complete a log. A statement of correction, along with a copy of this log, will be submitted into CCL for review by this LPA by the due date of 08/04/2022.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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, the licensee did not comply with the section cited above since a cleaning agent was present in a bathroom cabinet under the sink and not properly locked at this time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Facility designated Administrator will remove the cleaning agent or properly lock the cabinet at all times if any cleaning supplies are kept underneath there. A statement of correction will be submitted into CCL for review by this LPA by the due date of 08/04/2022.

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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/05/2022 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GELZHEN GUEST HOME LLC
FACILITY NUMBER: 392700557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since there was not a sufficient supply of 2-day perishable and 7-day nonperishable food quantities being maintained at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Facility designated Administrator will replenish the facility food supply for adequate 2-day perishable and 7-day nonperishable food quantities at all times. A statement of correction, along with a copy of newly purchased food supplies receipt, will be submitted into CCL for review by this LPA by the due date of 08/04/2022.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above since facility personnel were conducting injections for the residents who were unable to perform them unassisted and facility personnel were not licensed medical professionals at this time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Facility designated Administrator will review and update all Needs/Appraisal Care Plans for the residents requiring injections and unable to perform them unassisted at this time. New resident care plans will need to reflect any, and all facility personnel who are authorized by law, who will be present to perform injections as needed for all residents. A statement of correction, along with a copy of these updated care plans, will be submitted into CCL for review by this LPA by the due date of 08/04/2022.

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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/05/2022 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GELZHEN GUEST HOME LLC
FACILITY NUMBER: 392700557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since there were (4) storage units on site that were being used to store old, unused mattresses and furniture which were being considered to be thrown out. In addition, a large load of scrap wood and other discarded items were being collected under a tarp in the backyard area which poses/posed 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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Facility designated Administrator will remove all unwanted mattresses and furniture, as well as, the pile of scrap wood. A statement of correction, along with pictures of the empty sheds and cleared backyard area, will be submitted into CCL for review by this LPA by the due date of 08/010/2022.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5