<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602633
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:49:40 PM

Document Has Been Signed on 06/02/2023 03:49 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: 6DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administartor - Francis MejiaTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required- 1 year visit focusing on the CARE TOOL. LPA was greeted by DSP Asuncion Orosco and shortly after by Administrator Francis Mejia. LPA explained the purpose of the visit. The home has 6 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 and 2 Hospice Wavier Approval. Facility serves Dementia residents. This home is in a residential neighborhood and contains 5 bedrooms (4 residents and 1 staff), 1 hallway bathroom, 1 private bathroom and 1 staff bathroom, living room, dining room, kitchen, and a detached garage.

Facility has 2 residents on Hospice, 1 Bedridden , 1 resident on Home Health. Facility Number 909-741-7811. Liability Insurance Expires 5/5/24. Administrator certificate expires 05/22/24.
  • The following were observed/inspected:
  • LPA during tour with Asuncion observed PPE, hygiene supplies stored in hallway bathroom locked, linen/towels/and adult brief supplies in hallway closet locked.
  • Kitchen observed sanitary, functional equipment and sufficient, non-perishable and perishable food items for clients in care. Extra food in garage.
  • Hot water observed throughout the facility is within Title 22 regulation.
  • Toxins, disinfectants and cleaning products locked under kitchen sink and sharps locked in cabinet.
  • Resident rooms have adequate furniture and is clean and sanitary.
  • No large body of water observed, no firearms on premises and 2 fireplace are secured/gated.
  • Ramps, passageways and hallways are free of obstruction.
  • A posted Emergency Disaster Plan was observed , Ombudsman poster, Licensing poster, and Personal Rights
  • 6 Staff and 6 resident files were observed and no deficiencies noted.
  • Smoke detector, Carbon Monoxide were tested and operable. Fire extinguisher was charged and serviced. Last Fire Drill conducted on 5/30/23.
  • LPA Calderon conducted 2 staff interviews and 5 resident interviews.
  • LPA alongside with Orosco reviewed medication for 4 clients in care and medication record book. Medication centrally locked for 6 clients in care and stored in dining area closet.
  • Garage has ppe, cleaning items, detergent and laundry: dryer and washer machine. Garage is locked and inaccessible to residents. Staff room is maintained locked.


There were no deficiencies cited. An exit interview was conducted with DSP Asuncion Orosco . A copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1