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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413083
Report Date: 07/28/2021
Date Signed: 07/28/2021 04:11:31 PM

Document Has Been Signed on 07/28/2021 04:11 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GEM'S SENIOR LIVING IIFACILITY NUMBER:
336413083
ADMINISTRATOR:GERLITA HIGAFACILITY TYPE:
740
ADDRESS:28291 PORTSMOUTH DRIVETELEPHONE:
(951) 301-4134
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 6DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Gerlita Higa, LicenseeTIME COMPLETED:
04:20 PM
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Licensing Program Analyst Deborah Mullen conducted an unannounced visit to conduct an annual inspection. LPA was granted entrance and met with Gerlita Higa, Licensee.

LPA inspected the facility and observed the following:
The home is a 6 bedroom, two bath home with a living room and dining room. The bedrooms are furnished with a bed, dresser, night stand, chair and appropriate lighting for residents comfort. Staff and resident files are kept the staff room. Resident medications are locked and stored in a cabinet in the staff office. The facility had a complete first aid kit. Sharps, knives and chemicals are locked and stored under the kitchen cabinet. Facility is clean, sanitary and in good repair. Kitchen sinks/refrigerator/stove, toilets/sinks/showers/tubs, dinnerware supplies were also reviewed and are in good repair. There are exit alarms that are working on all exit doors. There is an adequate supply of linens, hygiene supplies and drawer and closet space for residents' belongings. Facility has smoke detector and carbon monoxide detector in working order. LPA observed a 7 day supply of non-perishable and 3 days of perishable food for resident.

The facility appears to be in compliance at this time. No deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed with and provided to the Licensees.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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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