<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413084
Report Date: 06/30/2025
Date Signed: 06/30/2025 05:39:22 PM

Document Has Been Signed on 06/30/2025 05:39 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GEM'S SENIOR LIVING IFACILITY NUMBER:
336413084
ADMINISTRATOR/
DIRECTOR:		GERLITA HIGAFACILITY TYPE:
740
ADDRESS:28701 PORTSMOUTH DRIVETELEPHONE:
(951) 672-1470
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 6CENSUS: 4DATE:
06/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Sri Gutta, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:57 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card.

Resident record review began- Four (4) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is not meeting documentation requirements.

Employee records review began- Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is not present.



Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 109.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Two (2) exterior window screens need to be repaired.
(Continued from LIC809, Page 2)
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2025
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 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GEM'S SENIOR LIVING I
FACILITY NUMBER: 336413084
VISIT DATE: 06/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from LIC809, Page 1)

Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. No emergency food and water was observed.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 06/2025. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 06/11/2025. There were no bodies of water observed.

Based on the information received during this visit today, the following eleven (11) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with Sri Gutta, LIC809D, Appeal Rights at the time of the exit interview and copies will be emailed to the facility and confirmation of receipt will be requested.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Delgado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87205(b)
Accountability of Licensee Governing Body
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado observation , interview and record review, the licensee did not comply with the section cited above in the Licensee corporation is suspended as of 06/30/2025 according to the California Secretary of State which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2025
Plan of Correction
1
2
3
4
Licensee will ensure corporation is active and email LPA by POC due date.
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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado observation, interview and record review, the licensee did not comply with the section cited above in R1 did not have an inventory of personal property in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will ensure an inventory is in resident's file and email a copy to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in Room #3 did not have any lamps for residents (2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will obtain lamps for room #3 and send picture to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no valid Administrative certification was observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will email a copy of the valid certificate to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no training was observed for S1 and S2 in files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will email copies of training to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R4 did not have a reappraisal in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will email copy of reappraisal to LPA by POC due date
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R1, R2, R3, R4 did not have completed signed pre-admission appraisals in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will email copies of the completed pre-admission appraisals to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R4 did not have a medical assessment in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will obtain a medical assessment for R4 and email a copy to LPA by POC due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R4 did not have an admission agreement in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will ensure R4 has a completed admission agreement in file and email a copy to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 06/30/2025 05:39 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 06/30/2025 at 04:49 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: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no emergency food and water was observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee wil obtain emergency food and water and email pictures to LPA by POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation (c) all window screens shall be in clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in exterior window screen is tethered and sliding window screen is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
1
2
3
4
Licensee will repair and replace screens and email pictures or receipt from vendor to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Yolanda Delgado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2025


LIC809 (FAS) - (06/04)
Page: 10 of 10