565800005-3-10-2023-29-AS-ASMH-CPSV5F-20230310150751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800005
Report Date: 03/10/2023
Date Signed: 03/10/2023 03:08:37 PM

Document Has Been Signed on 03/10/2023 03:08 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GEMILAN HOME CARE CENTER		FACILITY NUMBER:	565800005
ADMINISTRATOR:	MELANIE MARIN		FACILITY TYPE:	735
ADDRESS:	4310 CASPER COURT		TELEPHONE:	(805) 488-9424
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 4	DATE:	03/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Melanie Marin		TIME COMPLETED:	03:20 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Ashley Smith and Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 9:10 a.m. When the LPAs arrived, there was one staff and four clients present. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Melanie Marin arrived shortly thereafter.

The LPAs and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPAs began the inspection in the kitchen/food service area at 9:47 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:55 a.m., the LPAs and Administrator observed a few ants near the pantry. The Administrator stated they would clean out the pantry and ensure the area was free of pests.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced 4/2022. The LPAs observed required postings throughout the common space. The Administrator was advised to post the Community Care Licensing Personal Rights form on the bulletin board.

The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage is where the washer and dryer are held, including additional perishable food items. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GEMILAN HOME CARE CENTER	FACILITY NUMBER: 565800005
	VISIT DATE: 03/10/2023

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BEDROOMS: The LPAs observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: The two client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 112.8 degrees Fahrenheit.

RECORDS: Client records review began at 10:50 a.m. Client records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 11:58 a.m.; medications are centrally stored and locked in a cabinet in the living room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Staff schedule
- Surety Bond

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC809 (FAS) - (06/04)

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