198603242-12-9-2023-28-AS-BPEA-CYCTQZ-20231209135645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603242
Report Date: 12/09/2023
Date Signed: 12/09/2023 01:57:49 PM

Document Has Been Signed on 12/09/2023 01:57 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:	12/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Thomas Trice - Administrator		TIME COMPLETED:	02:15 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) Bennette Pena conducted the required-1 year inspection. LPA was allowed entry by Jaime Patena, Caregiver and Perseveranda Ramos and explained the purpose of today's visit. Administrators, Thomas Trice and Liza Trice arrived at 10am and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 09/01/2024. Administrator Thomas Trice stated that facility does not handle cash resources for the residents. The last fire drill was conducted on 12/07/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over. Facility has hospice waiver approved for 2. Current census is six (6) non ambulatory. Home consists of five (5) resident bedrooms, one (1) staff bedroom, (4) bathrooms, living room, dining room, family room, kitchen, backyard, and a detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed broken flooring supplies, trash and other miscellaneous items in the side yard. Smoke and carbon monoxide detectors are operational. LPA observed the fireplace in the living room was not adequately screened. One (1) fire extinguisher located in the kitchen entrance was serviced on 12/08/2023. Administrator stated that the laundry dryer is broken, but have already contacted a service technician to fix it. Service technician is scheduled to come in today, 12/09/2023 or tomorrow, 12/10/2023. All bathrooms toured were observed to be fully stocked with hand soap, and paper towels, and had the required grab bars and nonskid mats in place. All showers in bathrooms accommodate non-ambulatory clients. At 10:15am, hot water temperature readings were measured which are within the required 105-120 degrees Fahrenheit. Medication was observed to be centrally stored in the kitchen cabinet. *CONTINUED ON LIC 809-C

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

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: 12/09/2023

NARRATIVE

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Staffing: A total of seven (7) caregivers including the two (2) Administrators provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Administrator certificate is valid and will expire on 12/01/2024. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training.
Resident Records-Incident Reports: Three (3) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed.
Resident Rights-Information: Resident personal rights are posted. Physician order for use of 1/2 half and full bed rails were reviewed in (6) resident's files. One (1) resident did not have a written order from the Physician indicating the need for 1/2 (half) bed rail.
Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Administrators stated that the facility does not have dementia residents. However, dementia is part of the training for direct care staff and is included in the Plan of Operation.
Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. All sharps were observed to be stored in a kitchen drawer which was locked and inaccessible to residents. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. LPA observed that the kitchen sink base cabinet is not kept clean and close to breaking. Additionally, the base molding on one side of the wall in the kitchen is broken. LPA observed cleaning supplies and hazardous materials were stored in the food storage area in the detached garage. Plates, cups and utensils are kept cleaned and stored properly.
Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Currently, Home Health personnel service five (5) out of six (6) of the residents in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen. Four (4) residents' medications were reviewed to confirm medication is given as prescribed and is documented properly.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis for all staff and residents.
Residents with Special Health Needs: Five (5) out of the six (6) residents are receiving home health services. Postural support physician orders are on file. Two (2) half bed rail and two (2) full bed rail for mobility assistance was observed in four (4) residents in bedrooms #1, #3, #4 and #5. One (1) resident did not have a written order from the Physician indicating the need for 1/2 (half) bed rail. LPA observed that there are no oxygen in use signs posted in bedrooms #4 and #5 and both residents in the rooms are using oxygen. Individual Service Plans and Appraisals for residents are on file.

Deficiencies were cited, Technical Assistance issued, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Thomas Trice.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2023 01:57 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: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in which LPA observed cleaning supplies and hazardous materials were stored in the food storage area in the detached garage which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	Administrator agreed to store/organize the hazardous and cleaning materials in a locked and covered storage in the detached garage.Proof of correction such as photos will be submitted to CCL/LPA on or before the 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2023 01:57 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: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed that the kitchen sink base cabinet is not kept clean and close to breaking. Additionally, the base molding on one side of the wall in the kitchen is broken which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that the facility is kept safe and in good repair at all times. Administrator will submit proof such as photos and/or service report that the kitchen sink base has been cleaned and fixed on or before the POC due date.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed broken flooring supplies, trash and other miscellaneous items in the side yard which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator will submit photos that the side yard has been cleared and cleaned out and unobstructed to CCL/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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2023 01:57 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: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(7)

Personal Accommodations and Services

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed the fireplace in the living room was not adequately screened which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator agreed to purchase a screen and enclosed the open faced fire place and submit photos and receipt to CCL/LPA on or before POC due date.

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(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
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in that one (1) resident did not have a written order from the Physician indicating the need for 1/2 (half) bedrail which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	Administrator will submit the Physician order authorizing use of half (1/2) bed rail for the resident to CCL/LPA on or before the 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/09/2023 01:57 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: 12/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in that LPA observed that there are no "no smoking-oxygen in use" signs posted in bedrooms #4 and #5 for (2) residents using oxygen which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit photos of the "no smoking-oxygen in use" signs posted on bedrooms #4 and #5's doors and surrounding areas to CCL/LPA on or before the 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC809 (FAS) - (06/04)

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