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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006060
Report Date: 01/03/2025
Date Signed: 01/03/2025 02:56:50 PM

Document Has Been Signed on 01/03/2025 02:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:G & G HOME CARE INC.FACILITY NUMBER:
306006060
ADMINISTRATOR/
DIRECTOR:		DIZON, GERTRUDEFACILITY TYPE:
740
ADDRESS:24952 VIA MARFILTELEPHONE:
(626) 202-7651
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 6CENSUS: 6DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:10 AM
MET WITH:Gina Dizon and Rainelda ReyesTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to G & G Home Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents of which 2 may be bedridden. Facility has an approved hospice waiver for 3 residents and the home currently has 6 residents with 2 on hospice. Administrator Gina Dizon arrived during the visit.
LPA Lyman along with Caregiver toured the facility at 8:00 AM. Administrator Dizon joined the tour in progress. LPA toured the physical plant, checked food service, first aid kit and reviewed records. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, two common restrooms, three resident restrooms, living room, dining room, office and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident rooms are single occupancy. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 115.2 and 119.4 degrees F in all facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the elements including thermometer, tweezers and scissors as well as a manual. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan and infection control and plans are thorough and complete.
CONTINUED ON LIC 809C DATED 01/03/2024
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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: 01/03/2025
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Facility provides activities in the form of exercise, and games. LPA reviewed six resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of medical clearance/ TB, CPR and criminal record clearance as well as required training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today's visit, NO deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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