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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006060
Report Date: 12/13/2021
Date Signed: 12/13/2021 10:47:42 AM

Document Has Been Signed on 12/13/2021 10:47 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:G & G HOME CARE INC.FACILITY NUMBER:
306006060
ADMINISTRATOR:DEOSO, GEMMAFACILITY TYPE:
740
ADDRESS:24952 VIA MARFILTELEPHONE:
(949) 316-7820
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 0DATE:
12/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gemma Deoso and Rainelda ReyesTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Administrator/ Licensee Gemma Deoso and Licensee Rainelda Reyes. An initial application to operate a Residential Care Facility for the Elderly was received by CCL on 10/27/2021 for a capacity of four non-ambulatory residents and two bedridden.
LPA Lyman along with Administrator and Licensee toured the facility at 9:10 AM and observed the following:
Structure: Facility is a one story, 6 bedroom, 5 bathroom house with an attached garage and a light exterior. The exit gates are closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms will be a mix of single and double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: To be posted in entrance of facility. Food Service: Facility to obtain 2 day perishables upon acceptance of residents Facility has 7 day non-perishables. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: Facility to obtain locks for sharps and cleaning supplies in kitchen. Water Temperature: Tested and recorded between 78 and 130 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food. Facility to obtain emergency water supply.Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Medication to be stored and locked in a locked cabinet in the office. CONTINUED ON LIC 809C DATED 12/13/2021.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: G & G HOME CARE INC.
FACILITY NUMBER: 306006060
VISIT DATE: 12/13/2021
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Resident & Staff File: Records to be are stored in a file cabinet in the office. Reading Material, Games, and Equipment: Facility to provide activities depending on resident's choice. Backyard: LPA observed a clean backyard with ample shaded seating for residents. Fire Clearance: Approved for four non-ambulatory residents and two bedridden on 10/15/2021.

Licensee to address the following and forward proof to LPA by 12/27/2021:
  • Please adjust water temperature to be between 105 and 120 degrees F.
  • Please repair/ remove pipes in backyard.
  • Please install locks for sharps and cleaning supplies in kitchen.
  • Please maintain a thirty day supply of PPE on-site at the facility at all times.
  • Please obtain adequate bed sheets and drinking glasses.
  • Please enlarge the "Let Us No" sign to regulation size 20" X 26."
  • Please post activity schedule, sample menu, administrator certificate and emergency disaster plan..
  • Please obtain adequate emergency water.
  • Please install a self latching mechanism on the exit gate.
  • Please secure storage area in yard with a lock.
  • Please post hand washing signs in all restrooms as well as covid precaution signage at entrance to facility.


Component III was conducted during this visit as well.


The facility is not ready to be licensed. Licensee to notify LPA when corrections are completed.

An exit interview was conducted with Administrator and Licensee and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC809 (FAS) - (06/04)
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