565800005-5-1-2024-29-AS-ECOZ-D4UW3X-20240501165639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800005
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:57:25 PM

Document Has Been Signed on 05/01/2024 04:57 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GEMILAN HOME CARE CENTER		FACILITY NUMBER:	565800005
ADMINISTRATOR/ DIRECTOR:	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:	05/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Melanie Marin		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 1:15 p.m. When the LPA arrived, there was one staff and two clients present. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Melanie Marin arrived shortly thereafter. The remaining clients arrived during the visit.

The LPA 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 LPA began the inspection in the kitchen/food service area at 1:47 p.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.

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 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. However, at 1:57 p.m. the LPA did not observe a smoke detector in the staff room. Smoke detector was placed in staff room and tested during the visit. The LPA observed two (2) fire extinguishers in the facility fully charged and were last serviced 4/18/2024. The LPA observed required postings throughout the common space.

The backyard has a covered outdoor area equipped with furniture for client use. 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.

Report will continue on LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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

FACILITY NAME: GEMILAN HOME CARE CENTER	FACILITY NUMBER: 565800005
	VISIT DATE: 05/01/2024

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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 client restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathroom was sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 106.7 degrees Fahrenheit.

RECORDS: Client records review began at 2:15 p.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 3:47 p.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 LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Surety Bond

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalty issued for the amount of $500 Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2024 04:57 PM - It Cannot Be Edited

Created By: Esther Cortez On 05/01/2024 at 04:32 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GEMILAN HOME CARE CENTER	FACILITY NUMBER: 565800005
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one (1) out of four (4) rooms, as the staff room was observed without a smoke detector which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2024
	Plan of Correction
1 2 3 4	Plan of correction has been met, a smoke detector was placed during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kasandra Lopez

LICENSING EVALUATOR NAME:

Esther Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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