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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602634
Report Date: 06/09/2023
Date Signed: 06/09/2023 04:12:33 PM

Document Has Been Signed on 06/09/2023 04:12 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 #2FACILITY NUMBER:
198602634
ADMINISTRATOR:MEJIA FRANCISFACILITY TYPE:
740
ADDRESS:665 MT CARMEL DRIVETELEPHONE:
(919) 534-0132
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Caregiver/ Isajani DadinguinooTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required- 1 year visit focusing on CARE TOOL . LPA was greeted by Caregiver Isajani Dadinguinoo alongside with Caregiver Delza Lim. 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 Hospice Wavier for two (2). This home is in a residential neighborhood and contains 6 bedrooms: 5 resident bedrooms, 1 staff bedroom, 2.5 bathrooms, living room, dining room, kitchen, den and a attached garage / shed. Facility has 1 resident on Hospice, and 1 Bedridden. Administrator certificate expires 05/22/24.
  • The following were observed/inspected:
  • LPA during tour with Isajani observed PPE hygiene supplies stored in back hallway bathroom closet remains locked.
  • Linen/ sheets/ towels 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 were observed unlocked and stored in backyard, under kitchen sink cabinet and under the 2.5 bathroom sink cabinets. Deficiencies cited, See LIC 809-D.
  • Resident(s) rooms have adequate furniture and is clean and sanitary. LPA observed Resident 6 (R6) bedroom cabinet missing a door. Deficiencies cited, See LIC 809-D.
  • Staff room is maintained locked.
  • No large body of water observed, no firearms on premises and 1 fireplace observed.
  • Outside / Backyard Ramp in disrepair, deficiencies cited, see LIC 809-D
  • Passageways and hallways are free of obstruction.
  • A posted Emergency Disaster Plan was observed , Ombudsman poster, Licensing poster, and Personal Rights were observed.
  • 5 Staff files reviewed all cleared and have appropriate documentation's and 6 resident files were observed. Resident #1 and #6 did not have a TB report / results on file.
  • Smoke detector, carbon monoxide were tested and operable. Fire extinguisher was charged and serviced. Last Fire / Disaster Drill conducted on 06/02/23.
  • LPA Calderon conducted 1 staff interviews, 6 resident interviews.

Continuation 809-C...
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 198602634
VISIT DATE: 06/09/2023
NARRATIVE
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  • Signal System operable and in place for Dementia.
  • LPA alongside with Isajani reviewed medication for 4 clients in care and medication record book. Medication centrally locked for 6 clients in care and stored near entrance closet, no deficiencies cited.
  • Garage has storage items, cleaning items, detergent and laundry: dryer and washer machine. Garage is locked and inaccessible to residents.


The following deficiencies are being cited on the attached LIC809D page(s) under the Title 22 California Code of Regulations. Exit interview conducted, a copy of this report, 809-D's and Appeal Rights were given.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/09/2023 04:12 PM - It Cannot Be Edited


Created By: Ashley Calderon On 06/09/2023 at 03:28 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 #2
FACILITY NUMBER: 198602634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interviews , the licensee did not comply with the section cited above. 6 out of 6 in care are at risk due to LPA observing disinfectants and cleaning solutions not locked which poses an immediate health, safety or personal rights risk to persons in care. LPA observed unlocked items stored under kitchen sinks and bathroom sinks.
POC Due Date: 06/30/2023
Plan of Correction
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Staff during LPA's visit immediately removed cleaning solutions and disinfectants and stored in locked cabinets / storage space. Licensee / Administrator will provide LPA with In Service Training on the regulation cited and will show pictures to LPA on 2.5 bathrooms having a lock in the cabinets under the sinks and lock under kitchen sink .
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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/09/2023 04:12 PM - It Cannot Be Edited


Created By: Ashley Calderon On 06/09/2023 at 03:28 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 #2
FACILITY NUMBER: 198602634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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, 6 out of 6 persons, are at risk . LPA observed back yard ramp is broken and backyard shed missing door, resident # 6 cabinet missing a door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee will repair / fix/ replace backyard ramp, resident #6 cabinet and shed door and submit pictures to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/09/2023 04:12 PM - It Cannot Be Edited


Created By: Ashley Calderon On 06/09/2023 at 03:31 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 #2
FACILITY NUMBER: 198602634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation /interviews and record review, the licensee did not comply with the section cited above in 2 out of 6 persons (Resident #1 and Resident #6 ) which poses/posed a potential health, safety or personal rights risk to persons in care. LPA osberved no TB filed in residents files.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee to ensure each personnel record shall contain Tuberculosis test documents and submit a copy of Tuberculosis results to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023


LIC809 (FAS) - (06/04)
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