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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602633
Report Date: 03/05/2024
Date Signed: 03/05/2024 07:02:17 PM

Document Has Been Signed on 03/05/2024 07:02 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
GREATER LA AC/SC, 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:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Administrator Francis MejiaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1-year Visit on
03/05/2024. LPA was met by Administrator Francis Mejia and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which one (1) may be non-ambulatory and has a hospice waiver approved for two (2).

LPA OBSERVATIONS: The facility is a single-story dwelling located on a residential street and consists of four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory devices on entry of door to be operational, sliding door and exits.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located under kitchen sink, to be inaccessible to five (5) out of five (5) residents in care.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 70-degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.



SEE 809-C for continuation.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 4
Document Has Been Signed on 03/05/2024 07:02 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/05/2024 at 01:52 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and or visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Staff lowered water temperature during visit. **This will clear 24hr POC** Licensee will retrain staff on above regulation by 3/19/24. Proof of re-training must be sent by 3/19/24.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, keys to unlock cleaning supplies was observed to be resting on top of vanity mirror, the licensee did not comply with the section cited above in 2 out of 5 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Staff removed keys and placed in secure location. **This will clear 24hr POC** Licensee will retrain staff on above regulation by 3/19/24. Proof of re-training must be sent by 3/19/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/05/2024 07:02 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 03/05/2024 at 01:52 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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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 or tear down ADU and send picture proof.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GIANA'S HOME #1
FACILITY NUMBER: 198602633
VISIT DATE: 03/05/2024
NARRATIVE
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Resident Rooms 1-4: LPA Ramirez inspected four (4) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.

Bathrooms 1-3: Water temperature in two (2) resident bathrooms were not within 105-120 degrees F. Water temperature I bathroom#1 was measured at 127.8 degrees F and 127.6 degrees F in bathroom#2. LPA Ramirez will issue Type A deficiency. Bathtoom#3 is accessible only to staff. LPA Ramirez observed keys to unlock chemicals in bathroom#2 to be accessible to residents in care. LPA Ramirez will issue Type A deficiency.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed. LPA Ramirez observed staff room near garage area. According to Administrator Mejia, the facility does not have a city permit for additional room. On 10/31/2022, Case Management visit with deficiencies was conducted. Facility was previously cited for not having city building permit for additional staff room. LPA Ramirez will issue Type B deficiency.

Garage: Access to garage was observed to be inaccessible to five (5) out of five (5) residents in care. Extra PPE supplies observed in this area.

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last two (2) fire drills were conducted on 01/05/24 and 12/05/23. LPA Ramirez observed a First Aid kit in medication closet.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Francis C Mejia with an expiration date of 05/22/2024. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed.

Resident Records: Five (5) resident files were reviewed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, and Personal Rights Form were observed in resident records.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.



Deficiencies were cited during visit. Exit interview was conducted. A copy of this report, 809-D and appeals was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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