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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602634
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:31:09 PM

Document Has Been Signed on 04/04/2024 02:31 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 #2FACILITY NUMBER:
198602634
ADMINISTRATOR/
DIRECTOR:		MEJIA FRANCISFACILITY TYPE:
740
ADDRESS:665 MT CARMEL DRIVETELEPHONE:
(919) 534-0132
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 5DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:42 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 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 Analysts (LPAs) Kimberly Ramirez and Christian Gutierrez conducted an unannounced required Annual Inspection 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 bedridden 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 five (5) resident bedrooms, one (1) staff bedroom, two (2) full bathrooms, one (1) ½ bathroom, 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: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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 3
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 #2
FACILITY NUMBER: 198602634
VISIT DATE: 04/04/2024
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
26
27
28
29
30
31
32
Resident Rooms 1-5: LPA Ramirez inspected five (5) resident bedrooms and observed four (4) out of the five (5) bedrooms to contain required furnishings, lighting, and linens. Resident bedroom#2 did not contain a bed. Per interview with resident#1 (R1), R1 does not wish to have a bed in their room. R1 is independent and is not conserved. LPA Ramirez will issue Technical Advisory for exception for removal of R1 bed.

Bathrooms 1-2 ½ : Water temperature in two (2) ½ resident bathrooms were within 105-120 degrees F. LPAs observed non slip coating in showers.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed.

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 fire drills were conducted on 01/05/24. LPAs 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.



No deficiencies were cited during visit. One (1) Technical Advisory was issued. Exit interview was conducted. A copy of this report, LIC 9102 and appeals was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3