198603242-10-12-2024-28-AS-THEA-D9YRSR-20241012131710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603242
Report Date: 10/12/2024
Date Signed: 10/12/2024 01:17:20 PM

Document Has Been Signed on 10/12/2024 01:17 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	EUROPEAN CHRISTIAN HOME		FACILITY NUMBER:	198603242
ADMINISTRATOR:	TRICE, THOMAS		FACILITY TYPE:	740
ADDRESS:	9249 DALBERG STREET		TELEPHONE:	(562) 397-2591
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Liza Trice - Assistant Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by Percy (Caregiver) and the purpose for today’s visit was explained. Shortly after Assistant Administrator Liza Trice assisted with visit. The facility is licensed to serve 6 Non-Ambulatory residents ages 60 and above, with a hospice waiver for 2.

The facility is a single story home located in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 5 resident bedrooms (1 shared room), 1 staff bedroom, 4 bathrooms (1 staff, 1 visitor, 1 resident, 1 private in room 4), laundry room, detached garage, tool shed, front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following:

Infection Control: There is sufficient PPE supplies and Infection Control Plan is maintained at the facility.
Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.(Continued on LIC809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EUROPEAN CHRISTIAN HOME	FACILITY NUMBER: 198603242
	VISIT DATE: 10/12/2024

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Personnel Records-Training: Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, dementia, hospice and other ongoing training are documented in personnel files. LPA reviewed 5 staff files and observed Staff #3 to be missing their health screening and First-Aid certificate to be missing, citation issued and detailed on the LIC809-D. Administrators Thomas Trice and Liza Trice have valid certificates that expire in Dec. 2024.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 6 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Technical violation was issued as the fire drill record was not at the facility, per Assistant Administrator the log was taken to office to scan for record keeping as drill was conducted just last week, all previous logs for drills were documented only the current log was missing.
Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. Facility has the required "Oxygen in Use" signs posted.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be detailed on the LIC809-D.

Exit interview held and a copy of the report and appeal rights were provided to Assistant Administrator Liza Trice.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2024 01:17 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: EUROPEAN CHRISTIAN HOME	FACILITY NUMBER: 198603242
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 as LPA observed that Staff #3 was missing their Health Screening report, Assistant Admin was not able to obtain document during visit therefore citation issued, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to email a copy of Staff #3's Health Screening report that also shows result of (negative) TB test by POC due date. tena.herrera@dss.ca.gov

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 aboveas LPA observed that Staff #3 was missing their valid First aid certificate from file, per administrator staff completed training in April 2024 (cert expired 6/2024) but was not able to furnish proof of valid first aid certificate during visit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to provide a copy of Staff #3's valid first-aid certificate to LPA via email by POC due date. tena.herrera@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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

LIC809 (FAS) - (06/04)

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