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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413083
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:14:32 PM

Document Has Been Signed on 08/02/2022 12:14 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: 5DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Crispin Dizon - CaregiverTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Crispin Dizon and advised him of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA Colvin additionally went over the Infection Control items with Administrator Gerlita Higa via telephone, as the Administrator was unable to make it to the facility. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Gerlita Higa, who LPA Colvin found to be successfully incorporating the several aspects of the infection control, despite not having a Mitigation Plan on file. LPA Colvin inquired about if there was a copy at the facility for LPA Colvin to review (as there is no evidence that one has been submitted to Licensing) and the Administrator stated that there is not. LPA Colvin will be issuing a Technical Advisory Note for the facility not having a Mitigation Plan. LPA Colvin will not be issuing a deficiency as the Mitigation Plan request/requirement is outdated, and facilities are now being advised to submit an Infection Control Plan. Residents have hand sanitizer available to them, and 1 of 2 resident bathrooms were stocked with hand soap and paper towels. LPA Colvin observed the bathroom in the back hallway to have hand soap, but no paper towels. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note during today's inspection for the lack of paper towels as well as a deficiency for the common use of washcloths or towels, as LPA Colvin observed hand towels to be handing in the bathroom by the sink. It is a standard Title 22 Regulation that common towels are not be used. Deficiency cited.

While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the locked hallway closet. LPA Colvin observed the facility have an adequate supply of PPE.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GEM'S SENIOR LIVING II
FACILITY NUMBER: 336413083
VISIT DATE: 08/02/2022
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LPA Colvin went over the various recommended training for facility staff with Administrator Gerlita Higa in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Gerlita Higa confirmed that this has been done with the assistance of the local Public Health Department..

LPA Colvin observed 1 of 1 staff present (caregiver Crispin Dizon) to not be wearing any type of face covering. At this time, face coverings are still required in all residential facilities. LPA Colvin will be issuing a TA Advisory Note for 1 staff not wearing a face covering. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors are signing in to the facility, however, LPA Colvin was not able to confirm that they are being screened for symptoms, as LPA Colvin was not screened, there is no thermometer at the entrance of the facility or near the sign-in log, and there is no recorded temperature for the visitors on the sign-in log. LPA Colvin will be issuing a Technical Advisory Note for facility staff not screening visitors prior to entry.

An exit interview was conducted with caregiver Crispin Dixon, and a copy of this report, LIC809D, appeal rights, and LIC9102 TA Advisory Notes were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2022 12:14 PM - It Cannot Be Edited


Created By: Crystal Colvin On 08/02/2022 at 11:55 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GEM'S SENIOR LIVING II
FACILITY NUMBER: 336413083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(c)
Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 of 2 bathrooms, which poses a potential health risk to persons in care. LPA Colvin observed common use hand towels hanging in the back hallway bathroom near the sink. LPA Colvin observed that there were no paper towels in the bathroom or in the cabinet in the bathroom, therefore, this was the only means for residents and staff using this bathroom to dry their hands.
POC Due Date: 08/16/2022
Plan of Correction
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Licensee agrees to remove hand towels from the bathroom and ensure the bathroom is stocked at all times with paper towels and/or single-use towels. Licensee to submit Statement of Understanding regarding regulation and expectations for the continued health of residents, staff, and visitors. Statement of Understnading due by Plan of Correction date of 8/16/22.

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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
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