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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700557
Report Date: 11/21/2022
Date Signed: 11/22/2022 11:05:40 AM


Document Has Been Signed on 11/22/2022 11:05 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, 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:
11/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nichol Carbonell and Floyd LajaTIME COMPLETED:
02:30 PM
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Unannounced Plan of Correction visit made out to this facility on 11/21/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Nichol Carbonell, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the Licensee/Facility designated Administrator to let him/her know that CCL was present at this time.
Current census was 7 residents.
Facility Licensee, Floyd Laja, arrived later to this facility while this LPA was conducting this visit.
The purpose of this visit was to clear the deficiencies that were cited on previous annual visit dated on 08/03/2022 for the following deficiencies:
  1. (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).
  3. (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.
  5. (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.
  7. (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:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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: 11/21/2022
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5. 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.

Plan of Correction correction letters were printed and a copy was left with the facility designated representative, Floyd Laja, at this time.
There were no further deficiencies observed or cited during today's Plan of Correction visit.

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

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC809 (FAS) - (06/04)
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