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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603568
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:18:07 PM

Document Has Been Signed on 07/19/2024 03:18 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/
DIRECTOR:		TRICE, THOMASFACILITY TYPE:
740
ADDRESS:14402 HELWIG AVENUETELEPHONE:
(562) 397-2591
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 6DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Administrator Thomas Trice TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Jose Villalobos 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 Marisol Gomez. Administrator Thomas Trice arrived shortly after. The inspection was conducted using the CARE tools. The following CARE tools domains were utilized during the inspection.

Operational Requirements: 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. Required Liability Insurance is in place. A surety bond is not applicable. Facility does not handle resident's money. LPA still to complete this section at a later date.



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.

Resident Records/Incident Reports: A total of six (6) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.

Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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: 07/19/2024
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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.

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. Modified diets in place. \

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today.
There are currently six (6) Dementia residents 60 years and older residing in the facility. Two (2) residents receives home health, and two (2) are receiving hospice services.

Due to time constraints, LPA to return at a later date to complete the inspection. Six (6) of Twelve (12) Domains are still needed to complete inspection.

No deficiencies are being cited on todays visit. Exit Interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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