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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602633
Report Date: 04/20/2022
Date Signed: 04/20/2022 12:21:27 PM

Document Has Been Signed on 04/20/2022 12:21 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GIANA'S HOME #1FACILITY NUMBER:
198602633
ADMINISTRATOR:FRANCIS MEJIAFACILITY TYPE:
740
ADDRESS:4263 LA JUNTA DRIVETELEPHONE:
(909) 534-0132
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 5DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Administrator Francis MejiaTIME COMPLETED:
12:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by DSP Brain Tria and Administrator Francis Mejia arrived a short time later. LPA explained the purpose of the visit. The home has 5 residents at time of visit. This home is licensed to serve Elderly residents age 60 and above, (6) Non-Ambulatory of which 1 may be Bedridden. This home is in a residential neighborhood and contains 5 bedrooms: 2- private resident bedrooms, 2 semi-private resident bedrooms, 1 staff bedroom/bathroom, 2 bathrooms, living room, dining room, kitchen, and a detached garage. The last fire drill was completed on March 24, 2022. Administrator certificate expires 05/22/22

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Four (4) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All resident rooms were not equipped with alcohol-based hand sanitizer but available through out the facility
· Five (5) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies cited (please see 809D for details)

Exit interview was conducted with Administrator Francis Mejia. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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Document Has Been Signed on 04/20/2022 12:21 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/20/2022 at 12:02 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GIANA'S HOME #1
FACILITY NUMBER: 198602633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review. The licensee did not comply with the section cited above in 4 of 5 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
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Administrator will contact phycisian and get PRN orders for R1 -R4 and email proof by POC date to LPA.
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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/20/2022 12:21 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/20/2022 at 12:02 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GIANA'S HOME #1
FACILITY NUMBER: 198602633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. LPA and administrator observed 2 bathroom sinks that were back up which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Administrator will repair drain and send video and certify that it the sinks have been repiaired by POC date.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation. the side door latch to the door on the right side of the home is broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Administrator will repair door and send pictures as proof of correction to LPA by POC 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:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
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