198603247-12-22-2023-11-AS-JCAN-CYQQFK-20231221110803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603247
Report Date: 12/21/2023
Date Signed: 12/22/2023 08:04:50 AM

Document Has Been Signed on 12/22/2023 08:04 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	EVERLASTING HOME CARE		FACILITY NUMBER:	198603247
ADMINISTRATOR:	BULLER, KATHRINA		FACILITY TYPE:	740
ADDRESS:	5413 BROCKWOOD STREET		TELEPHONE:	(562) 421-4855
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 6	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	STAFF MARIA MICLAT		TIME COMPLETED:	11:30 AM

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	On 12/21/2023 at 08:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Everlasting Home Care Facility. LPA Calderon was allowed entry into the facility by Staff Maria Miclat. Staff Maria Miclat asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) adult clients 59 year or older. Currently, there are six (6) residents residing in the facility 59 years or older. LPA Calderon explained to Staff Maria Miclat, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Six (6) resident service records, six (6) resident medication records, two (2) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed six (6) residents and two (2) staff members for visit. The facilities’ last fire drill was conducted on 08/17/2023. The one-story residential home consists of (4) resident bedrooms, (2) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water supply is found in a storage closet.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EVERLASTING HOME CARE	FACILITY NUMBER: 198603247
	VISIT DATE: 12/21/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 113 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 114 degrees Fahrenheit. Facility (2) carbon Monoxide and (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility 2 first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon reviewed six (6) resident medications and they were all found to be administered according to doctor's orders. LPA Calderon noted the Administrator Kathrina P Buller Certification # 6042683740 expiration date of 10/30/2024 was valid at time of visit. The facility does NOT handle resident's money/cash resources and NO Surety bond is needed. Commercial General Liability Policy #PCI3397484501 policy period from 01/22/2023 to 01/22/2024 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. All the required documents are posted in the facility in a clearly visible area.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: EVERLASTING HOME CARE	FACILITY NUMBER: 198603247
	VISIT DATE: 12/21/2023

NARRATIVE

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During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were NOT wearing face coverings and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Staff Maria Miclat to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Maria Miclat.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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