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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603402
Report Date: 03/27/2023
Date Signed: 03/27/2023 05:21:51 PM

Document Has Been Signed on 03/27/2023 05:21 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:RHEMA CARE GROUP LLC - HOLLY OAK DRIVEFACILITY NUMBER:
198603402
ADMINISTRATOR:IRHIA, BLESSINGFACILITY TYPE:
735
ADDRESS:1820 E HOLLY OAK DRIVETELEPHONE:
(626) 426-5904
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Wilson Ekaun-John TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with DSP Jackie Huicar allowed the entry of the facility. Shortly after, LPA met with the administrator Wilson Ekaun-John and assisted with the visit. The purpose for the visit was explained. The facility is licensed for Age Range 18 through 59 for Ambulatory only.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and only inspected those domain:

1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental: The facility is a single story house and located around the neighborhood area. The facility includes: living room, dining area, kitchen, four clients bedrooms, two clients bathrooms and a detached garage. The window screen in the 4th client's bedroom was broken and it does not have the light switch cover. Also there's a hole on the entrance wall. LPA inspected the carbon monoxide detectors and smoke detectors and they are all working properly. LPA tested the hot water in the two client bathrooms and they were tested between 117.1 and 117.5 degrees F which is is within the Title 22 regulation. All the sharp knives and chemicals are locked in the file cabinet near dining area and hallway cabinet. Also for the 1st client's bedroom, it does not have the fitted bedsheet.
3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which they currently have 4 ambulatory clients only. The facility also has shaded area with table and chair for client to utilize for outdoor activity. The last fire and earthquake drill was conducted on 2/14/23.

(See LIC 809C for continuation)



SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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 4
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: RHEMA CARE GROUP LLC - HOLLY OAK DRIVE
FACILITY NUMBER: 198603402
VISIT DATE: 03/27/2023
NARRATIVE
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4.Staffing: The Night supervision staff does have the required training for the planned emergency procedure. There is sufficient staffing at the facility.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator's (Wilson Ekaun-John) certificate expires on 8/8/2023. The administrator also has an updated HIV and TB Training. All the direct care staff has the updated first aid training.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Food Service: The facility has two days perishable and seven days non-perishable food supply. The refrigerator is maintained in the required temperature. All the food are stored probably.
8. Health Related Services: All client medication are centrally stored in the file cabinet next to the dining area. LPA inspected Client#1's medication Tamsulosin HCL 0.4mg Capsule and take one capsule by mouth at bedtime. On the pharmacy record, it stated taking it AM but on the bubble pack is bedtime. For client#2 PRN medication Enulose and Polyethylene Glycol and its not listed on MARs. The first aid kit has all the required items. Staff also have required medication training in their personnel file.

Due to time restrains, LPA was not able to complete the annual inspection by using the CARE tools. LPA will come back another time to finish the following domain which include: Client's Record-Incident Reports, Incidental Medical Services, Disaster Preparedness and Emergency Intervention.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the administrator Wilson Ekaun-John.




SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/27/2023 05:21 PM - It Cannot Be Edited


Created By: Christine Wong On 03/27/2023 at 03:14 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RHEMA CARE GROUP LLC - HOLLY OAK DRIVE
FACILITY NUMBER: 198603402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observec Client#1's medication Tamsulosin HCL 0.4mg Capsule and take one capsule by mouth at bedtime. On the pharmacy record, it stated taking it AM but on the bubble pack is bedtime. For client#2 PRN medication Enulose and Polyethylene Glycol and its not listed on MARs. poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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The administrator will ensure the medication, once ordered by physician the medication is given according to the physician's directions. The administrator will contact pharamcy and updated the MARs
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/27/2023 05:21 PM - It Cannot Be Edited


Created By: Christine Wong On 03/27/2023 at 03:14 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RHEMA CARE GROUP LLC - HOLLY OAK DRIVE
FACILITY NUMBER: 198603402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed the window screen in the 4th client's bedroom was broken and it does not have the light switch cover. Also there's a hole on the entrance wall and the 1st client's bedroom, it does not have the fitted bedsheet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The administrator will ensure the facility shall be clean, safe, sanitary and in a good repair at all times. The administrator will fixed the 1. window screen on 4th client's bedrooms, 2. light switch cover and 3. the hole from the entrance wall. and send the picture to LPA by POC due date.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , LPA observed the 1st client's bedroom, it does not have the fitted bedsheet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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The administrator each client should have bed sheet, pillow cases...etc. The adminsitrator will place a fitted bed sheet in first client bedroom and send the picture 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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