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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603402
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:28:03 PM

Document Has Been Signed on 03/30/2023 04:28 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:
03/30/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Wilson Ekaun-John TIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 3/27/2023 but due to time restrains and LPAs Christine Wong and Tena Herrera has returned on today's date 3/30/2023 to finish the remaining four (4) domains. LPA met with DSP Jackie Huicar who allowed entry into the facility and Shortly after, the Administrator Wilson Ekaun-John was arrived and assisted with the visit

On today's date, LPA inspected the four (4) domains include: Client's Record-Incident Reports, Incidental Medical Services, Emergency Intervention and Disaster Preparedness.

Client's Record-Incident Reports: The clients files are maintained in the facility. The client files have the required documents which included admission agreement, face sheet, Individual Personal Plan (IPP) and physician report but Client#2-#4's physician report did not indicate the client's ambulatory status and TB test result.
Incidental Medical Services: It does not apply to the facility. Facility does not have any clients have restricted health condition and prohibited health condition
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: All the staff has CPI training and it's up-to-dated.

On today's visit, LPA interviewed three (3) staff but no client interview was able to interview due to their unavailability.

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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 2
Document Has Been Signed on 03/30/2023 04:28 PM - It Cannot Be Edited


Created By: Christine Wong On 03/30/2023 at 11:57 AM
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: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPAs observed C2-C4 hysician report does not have the ambulatory status and TB test result which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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The administrator will get an updated phyisican report which include client's ambulatory status and TB test result and send to LPA by POC due date.
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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2