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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602633
Report Date: 10/31/2022
Date Signed: 10/31/2022 12:54:48 PM

Document Has Been Signed on 10/31/2022 12:54 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:
10/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Brian Tria, CaregiverTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza made an unannounced visit to investigate complaint control #: 28-AS-20221026164421. LPA discussed the purpose of the visit with Caregiver staff Brian Tria. Licensee/Administrator Francis Mejia was explained the purpose of the visit telephonically.

A physical plant tour of the facility was completed. The following observations were made:

  • The Office room was converted to a live-in staff room. Two (2) bunk beds were observed.
  • An additional live-in staff room was constructed inside the garage without obtaining a city permit or notifying Community Care Licensing. One (1) bed and staff personal belongings were observed.
  • The LIC 500 Personnel Report and resident roster are not updated. Licensee agreed to update the resident roster and LIC 500 Personnel Report.

Licensee/Administrator was instructed to obtain a city permit for the building alteration in the garage. In addition, an updated Plan of Operation and facility sketch shall be submitted to Community Care Licensing.

Deficiency has been cited. See LIC 809D.

Exit interview was held with caregiver staff Brian Tria. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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 10/31/2022 12:54 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/31/2022 at 11:53 AM
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited
CCR
87305(a)

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Alterations to Existing Building or New Facilities. Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement was not met evidenced by:
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Licensee/Administrator agreed to comply with city and state regulations:
1. Apply for a city permit
2. Update the Plan of Operation (include that a permit request was submitted to the city)
3. Update the facility sketch
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Based on physical plant inspection it was observed that the Office room was converted into a live-in staff room for 2, and a additional live-in staff room was constructed inside the garage without obtaining a city permit or notifying Community Care Licensing; which pose a potential health and safety risk to persons in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022


LIC809 (FAS) - (06/04)
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