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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198204036
Report Date:
11/23/2024
Date Signed:
11/23/2024 06:52:28 PM
Document Has Been Signed on
11/23/2024 06:52 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
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
ADMINISTRATOR/
DIRECTOR:
ERLINDA HATMAL
FACILITY TYPE:
740
ADDRESS:
4321 N. COUNTRY CLUB LANE
TELEPHONE:
(562) 290-0122
CITY:
LONG BEACH
STATE:
CA
ZIP CODE:
90807
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
6
DATE:
11/23/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:
Ivy Jane T Bertulfo
TIME VISIT/
INSPECTION COMPLETED:
01:59 PM
NARRATIVE
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On 11/23/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Ivy Jane Bertulfo and explained the purpose of today’s visit. The facility is licensed to operate for five (5) non-ambulatory of which one (1) may be bedridden elderly adults ages 60 and above.
The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (3) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area.
LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.5 degree F. A comfortable temperature of 71 degree was maintained in the facility.
LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A landline telephone was in working condition. A review of staff CPR/First Aid training is current.
Evaluation Report Continues LIC 809-C
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
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
8
Document Has Been Signed on
11/23/2024 06:52 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Section Cited
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA identified and observed resident #6 was tied/restrained around the waist while in a wheelchair. Licensee did not have physician's orders to indicate postural support is required. This violaiton which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2024
Plan of Correction
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Licensee will ensure to adhere to Title 22 Reg 87608. Licensee will request for a physicians order for postural support to restrain resident with a gait belt. The licensee will notify CCL and request for an exception for resident #6.
*corrected during visit - restraint removed*
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
11/23/2024 06:52 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above. LPA observed cleaning disenfectant solutions, over the counter medications in room #1, gardening supplies and sharp object found in bathroom #1 accessible to dementia residents in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulations 87705 and ensure that all hazardous, toxic, and harmful items are stored in locked storage and accessible to dementia residents in care. Proof of correction must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
11/23/2024 06:52 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA was informed by staff #1 no staff have completed hoyer lift training. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/14/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulations 87411 and ensure that all staff that have direct care to residents have hoyer lift training completed. Proof of correction must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
11/23/2024 06:52 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed that facility did not maintain a Medication Administration Record for prescribed medications and PRN for residents in care. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/14/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulations 87465 and ensure that facility maintains a Medication Administration Record for recordkeeping of prescribed medications and PRN for administration of medications. Proof of correction must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified the facility has not conducted quarterly Fire Drills. The last Fire Drill was in January 2024. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/14/2024
Plan of Correction
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Licensee will adhere to Health and Safety Regulation 1569.695 and ensure that quarterly fire drills are performed. Proof of correction must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
11/23/2024 06:52 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA identified staff #4 and #5 did not have competed required training on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/14/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulations 87705 and ensure that all staff a fully trained that have direct access to dementia residents in care. Proof of correction of completed training must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited. The facility did not have a LIC 500 and was not able to verify if one "awake" staff is schedule for night shift. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/14/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulations 87705 and ensure that a current LIC 500 Personnel Report and proof of at lease one "awake" staff is scheduled for night shift. Proof of correction must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
11/23/2024 06:52 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA identified residents #2, #3 and #6 did not have annual medical and reappraisal assessment done annually. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/14/2024
Plan of Correction
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2
3
4
Licensee will adhere to Title 22 Regulations 87705 and ensure to obtain annual medical and appraisal for residents diagonsed with dementia for residents #2, #3 and #6. Proof of correction must be sent to LPA by due date at ernand.dabuet@dss.ca.gov.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
Janae Hammond
TELEPHONE:
(424) 544-1027
Ernand Dabuet
TELEPHONE:
(323) 629-5526
DATE:
11/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC
,
400 CONTINENTAL BLVD, STE 340
EL SEGUNDO
,
CA
90245
FACILITY NAME:
EUGENIA'S HOUSE
FACILITY NUMBER:
198204036
VISIT DATE:
11/23/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.
LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 01/31/24 - 01/31/25. The facility is not current on Community Care Licensing annual dues with an open balance of $1237.00.
An audit of residents #1-#6 (R1-R6) service files and staff #1-#7 (S1-S7) personnel files revealed to be maintained in order. The facility has the current administrator's certification on file for Ivy Jane Bertulfo #605680740 - Expiration 02/16/25.
Deficiencies:
Facility has not conducted quarterly fire drills.
Facility staff #1-#6 all did not have hoyer lift training.
Hazardous materials, cleaning disinfectant, sharp object, and prescribed medications not stored in locked storage.
Resident #6 a fall risk was restrained with an authorized material while in a wheelchair without a physicians order.
Facility staff #4 and #5 did not have complete training on file.
Facility did not maintained documentation Medication Administration Records for prescribed and PRN medications.
Facility did not supply a LIC 500 Personnel Report, unclear if an "awake" staff is scheduled for NOC shift.
Facility has not conducted annual medical and appraisal for resident #2, #3 and #6 diagnosed with dementia.
An exit interview was conducted with
Ivy Jane Bertulfo
,
and a copy of the report was provided.
SUPERVISOR'S NAME:
Janae Hammond
TELEPHONE:
(424) 544-1027
LICENSING EVALUATOR NAME:
Ernand Dabuet
TELEPHONE:
(323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE:
11/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/23/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8