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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603568
Report Date: 08/19/2022
Date Signed: 08/19/2022 01:20:54 PM

Document Has Been Signed on 08/19/2022 01:20 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
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: 4DATE:
08/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Thomas Trice, licenseeTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a Pre-licensing inspection on 8/19/22. LPA met with Thomas Trice, the licensee. An application was submitted to CCLD on 3/18/22 for a Change of Ownership for a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 6 residents, 5 of which may be non-ambulatory and 1 may be bedridden. There are currently 4 residents residing at the facility.

LPA inspected and observed the following:

Facility is a one story home which consists of 4 resident rooms and 1 staff room, 2 bathrooms, living room, dining area, kitchen, and office area. The spacious backyard consists of a shaded area with table and chairs. There are no obstructions to the walkways and driveways. There are no pools or bodies of water at the facility.

The facility has an auditory device on each of the exit doors.

Bedrooms #1, #2, #4 are approved for non-ambulatory residents and bedroom #3 for bedridden. Bedrooms are equipped with a bed, nightstand, chair, and adequate closet space. There is adequate lighting throughout the room. There is one bathroom designated for residents use and another for staff. The bathroom has a walk-in shower and built in non-skid tiles. The hot water temperature was measured between 105-120 degree Fahrenheit. Extra bath towels, hand towels, wash cloths, blankets, bed linens were observed. Knives and sharps are locked and stored in the kitchen cabinet. Disinfectants and cleaning solutions are stored in the laundry room. The kitchen area consists of a refrigerator, microwave, and stove which are functional. Sufficient dishes and utensils were also observed. There are sufficient food supply of 2 day perishable and a week of non perishable on the premises.

(Continue on LIC809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: EUROPEAN CHRISTIAN HOME V
FACILITY NUMBER: 198603568
VISIT DATE: 08/19/2022
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Emergency disaster plan, Personal Rights, Resident Councils Complaint procedures, along with the post labor information are either posted on the wall or in a binder. There are operable smoke detectors in each room and a carbon monoxide detector at the facility. The fire extinguisher is fully charged and inspected on 3/2/22. The medications are stored and locked in a cabinet. Staff and resident files are maintained at the facility.

The facility phone number is (562) 404-8387.

Component III was conducted today and information was provided about how to operate the facility within substantial compliance. LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit

An exit interview was conducted and a copy of this report has been furnished to the applicant.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
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