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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413084
Report Date: 06/16/2023
Date Signed: 06/16/2023 05:52:53 PM

Document Has Been Signed on 06/16/2023 05:52 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GEM'S SENIOR LIVING IFACILITY NUMBER:
336413084
ADMINISTRATOR:GERLITA HIGAFACILITY TYPE:
740
ADDRESS:28701 PORTSMOUTH DRIVETELEPHONE:
(951) 672-1470
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 3DATE:
06/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Rodrigo BaluyutTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual required visit on 6/16/2023 at 12:20 PM LPA was granted entry and met with Staff Rodrigo Baluyut (Rolly) who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (3) clients present.
Buildings and Grounds: The home is composed of six (6) bedroom, five (5) client bedrooms, one (1) staff bedroom, three (3) bathrooms, a laundry area located in the garage, kitchen and dining area, and a front/back yard area. The interior walkways of the home were observed to be clutter free with no obstruction. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Rolly, there are no weapons stored in the home. Rooms, furniture, beds, mattresses appeared to be in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas are clutter free and in good condition. The LPA tested the hot water temperature, which was registered at 114.3 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order.
Storage and Supplies: The first aid kit components was observed to be available and complete and found in the hallway closet. Cleaning supplies stored in the bathroom under the sink and locked in cabinets. Linens, and equipment appeared to be in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged.
Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps stored in the kitchen pantry under the sink. Additional knives were found in accessible overhead cabinet near the stove which is not is not in compliance.

Record Review and Resident/Staff Files: LPA reviewed all staff files and reviewed the facility's staff schedule. All staff have criminal clearance. Staff member providing care has all proper documentation. Three (3) client files were reviewed and 2/3 files had resident admission agreements, 1/3 files were missing all residents documents including current physician report.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 16
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GEM'S SENIOR LIVING I
FACILITY NUMBER: 336413084
VISIT DATE: 06/16/2023
NARRATIVE
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Health Related Services/ Incidental Medical Services: All client medication was stored in an unlocked in a file cabinet across from the refrigerator. LPA reviewed client medications for (2) clients and found all medication listed on centrally stored lists and all required labeling was found to be in place. The medications were not properly being administered and no medication log found.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation with no proof a any fire or earthquake drills, proof showing the emergency and disaster training, which did not met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed no emergency food supply or water in any location of the facility.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Personal Rights, and Facility Sketch (LIC 999)



Deficiencies were cited during this visit. An exit interview was conducted where a copy of this report was provided to staff Rodrigo Baluyut (Rolly).
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 16
Document is an Amendment of Original Document on 06/19/2023 02:06 PM


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GEM'S SENIOR LIVING I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with staff and record review, the licensee did not comply with the section cited above in 1 out of 1 CPR records, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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2
3
4
Staff is CPR and First Aid Certified and remain current on certification.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations with medications stored in a file cabinet, the testimony from staff, the medications stored were in an unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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2
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Administrator agrees to lock the file cabinet containing medications.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 3 of 16
Document is an Amendment of Original Document on 06/19/2023 02:27 PM


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GEM'S SENIOR LIVING I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 5 of 16
Document Has Been Signed on 06/16/2023 05:52 PM - It Cannot Be Edited


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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 I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(1)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 7 of 16
Document Has Been Signed on 06/16/2023 05:52 PM - It Cannot Be Edited


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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 I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
CCR
87212(b)(1)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 8 of 16
Document is an Amendment of Original Document on 06/19/2023 02:17 PM


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GEM'S SENIOR LIVING I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87212(b)(2)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on documents posted in the facility, interview with staff, and record review The documents present on site, and the testimony of the staff the licensee did not comply with the section cited above in 1 out of 1 documents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
The Administrator agrees to provide the department with the evacuation plan for the facility.
Type A
Section Cited
CCR
87212(b)(2)(A)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on documents posted in the facility, interview with staff, and record review The documents present on site, and the testimony of the staff the licensee did not comply with the section cited above in 1 out of 1 documents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
1
2
3
4
The Administrator agrees to provide the department with the evacuation plan for the facility.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 9 of 16
Document Has Been Signed on 06/16/2023 05:52 PM - It Cannot Be Edited


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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 I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87212(c)
Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 11 of 16
Document Has Been Signed on 06/16/2023 05:52 PM - It Cannot Be Edited


Created By: Cheryl Goodrich On 06/16/2023 at 05:21 PM
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 I
FACILITY NUMBER: 336413084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Cheryl Goodrich
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
Page: 12 of 16