<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603568
Report Date: 09/21/2023
Date Signed: 10/10/2023 07:58:40 AM


Document Has Been Signed on 10/10/2023 07:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:EUROPEAN CHRISTIAN HOME VFACILITY NUMBER:
198603568
ADMINISTRATOR:TRICE, THOMASFACILITY TYPE:
740
ADDRESS:14402 HELWIG AVENUETELEPHONE:
(562) 397-2591
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 5DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Thomas TriceTIME 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) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to caregiver Mariesol Gomez. There are currently 5 Dementia residents 60 years and older residing in the facility. Two (2) residents receives home health, and none are receiving hospice services. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were utilized during the inspection.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed.
  • The facility has a Dementia Waiver in place. A Hospice Waiver for 4 is approved.
  • A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 3 only.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current and expires 4/9/2024.
  • A surety bond is not applicable. Facility does not handle resident's money.


****Narrative report continues next page.*****
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EUROPEAN CHRISTIAN HOME V
FACILITY NUMBER: 198603568
VISIT DATE: 09/21/2023
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
26
27
28
29
30
31
32
Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood consisting of 4 resident bedrooms (2 shared and 2 private), 2 bathrooms, living room, dining room, kitchen, den, live-in staff room, outdoor covered patio area, carport, and detached laundry room.
  • 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. Kitchen drawers containing knives/sharp objects were locked and inaccessible to residents in care.
  • The facility has one (1) fully charged fire extinguisher and a fire pull alarm.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature readings varied between low (92 DF - 113 DF) and high readings. Administrator adjusted the water heater and was advised to monitor water temperature for at least 2 days.

Staffing:
  • A total of five caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 12/1/2024.
  • Personnel files were reviewed. It was noted that staff files had previous Licensee's names on some forms. Several staff files were not in premises. Electronic staff files and documents were provided during today's visit. Proof of staff training was reviewed. Current 1st Aid/CPR records are current.

Resident Records/Incident Reports:
  • A total of five (5) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed.
  • The facility does not have a Resident Council.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EUROPEAN CHRISTIAN HOME V
FACILITY NUMBER: 198603568
VISIT DATE: 09/21/2023
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
26
27
28
29
30
31
32
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for a modified diets is in place.

Incident Medical and Dental:
  • 30-day supply of resident medications were observed. Centrally Stored Records for medications are kept.
  • Resident (R3's) Rx order (1/6/2023) Lisinopril 20 mg/hydrochlorothiazide 12.5 mg is listed on resident records as "Lisinopril HCTZ 10-12.5 mg". Therefore, the exact physician order dosage was incorrectly documented on R3's records. Staff acknowledged they had not noticed that there was a difference in dosage on the medication bottle and their records. No physician order was on file. Citation was issued.
  • Medical and dental transportation is provided by family members.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place and was posted today.
  • The last emergency disaster drill was conducted 8/16/2023.

Residents with Special Health Needs:
  • Two (2) residents receive home health services.
  • Postural support i.e. hoyer lift is used for one resident. Physician order is on file.
  • A total 4 residents [ R2, R3, R5 & R6] had full and/or two half rails side by side, converting it into full rails on each side, and none of the residents are in hospice. Citation was issued.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.
***Due to technical issues Administrator did not sign the report, nor was the report and appeal rights issued. On 9/22/23, LPA spoke to Administrator and sent the report/appeal rights and requested the report be signed and returned to LPA.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/10/2023 07:58 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: EUROPEAN CHRISTIAN HOME V
FACILITY NUMBER: 198603568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)(2)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.

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 in that resident (R3's) Rx order (1/6/2023) Lisinopril 20 mg/hydrochlorothiazide 12.5 mg, is listed on resident records as "Lisinopril HCTZ 10-12.5 mg”. Therefore, the exact physician order dosage was incorrectly documented on R3's records, staff acknowledged they had not noticed that there was a difference in dosage on the medication bottle and their records and no physician order was on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
1
2
3
4
Administrator shall submit:
1. A written plan of correction that states how the deficiency was corrected.
2. Conduct staff training and submit training document that includes training topic, presenter, and staff signatures.
3. Copy of the corrected Centrally Stored records and pharmacy order.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that a total 4 residents [ R2, R3, R5 & R6] had full and/or two half rails side by side, converting it into full rails on each side, but none of the residents are receiving hospice services, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
1
2
3
4
Administrator shall submit copies of R2, R3, R5, & R6's physican order for half bed rails. Pictures were taken.
NOTE: During the visit Licensee/Administrator called the resident's physicians and requested bed rail physician orders.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4