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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413083
Report Date: 06/05/2024
Date Signed: 06/05/2024 11:51:27 AM

Document Has Been Signed on 06/05/2024 11:51 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GEM'S SENIOR LIVING IIFACILITY NUMBER:
336413083
ADMINISTRATOR/
DIRECTOR:
GERLITA HIGAFACILITY TYPE:
740
ADDRESS:28291 PORTSMOUTH DRIVETELEPHONE:
(951) 301-4134
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 4DATE:
06/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:LICENSEE, GERLITA HIGATIME VISIT/
INSPECTION COMPLETED:
11:58 AM
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On June 05, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with Gerlita Higa, the Licensee. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site.

LPA Mixson toured the facility along with the Licensee and inspected the facility inside and outside, and there was no debris or obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home located at 28291 Portsmouth Drive, Sun City, CA. 92586.

Physical Plant: The facility phone number is (951) 301-4134. The LPA observed the residents’ bedrooms. Each bedroom was equipped with required furniture as per Title 22. LPA Mixson inspected facility bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, appliances were operating appropriately currently at the time of this visit, and exit signs were observed. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. The cleaning supplies and sharp items were locked and inaccessible to the residents in care at the time of this visit. A designated storage space for the residents and staff files was observed, and it was locked and inaccessible to residents in care currently at the time of this visit. The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit. There were safety lights for night.

Medications: The medications were locked and inaccessible to residents in care. There is a sufficient supply of medication for each resident currently.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharps are locked.

Care & Supervision: Facility has sufficient staff, two staff on site at the time of this visit, and the staff were engaging the residents with morning meals and medications.

Records Review: LPA Mixson reviewed resident files, along with staff files, conducted staff interviews. Residents were occupied with morning meal and medication management. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was given to the Licensee, Gerlita Higa

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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