198603568-9-18-2025-28-AS-NGAA-DLMRJ5-20250918130322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603568
Report Date: 09/18/2025
Date Signed: 09/18/2025 01:03:33 PM

Document Has Been Signed on 09/18/2025 01:03 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 V		FACILITY NUMBER:	198603568
ADMINISTRATOR/ DIRECTOR:	TRICE, THOMAS		FACILITY TYPE:	740
ADDRESS:	14402 HELWIG AVENUE		TELEPHONE:	(562) 397-2591
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 6		CENSUS: 6	DATE:	09/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:21 AM
MET WITH:	Thomas Trice, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:05 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to caregiver Salvador Huerta. Administrator Thomas Thrice arrived shortly after. The facility serves elderly residents ages 60 and older.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed and includes environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment.

Operational Requirements: A Dementia and hospice waiver for 4 residents has been approved. A fire clearance for 6 non-ambulatory and 1 bedridden resident is in place. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 10/21/2025.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. 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. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. The last Emergency Disaster drill was conducted on 6/28/2025. Oxygen was in use in room #1, but no sign was posted.

Staffing: A total 7 staff members provide care and supervision to the clients.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 09/18/2025

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Personnel Records/Staff Training: Administrator certificate expires 12/1/2026. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current.

Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Medication Administration records are in place.

RCFE and Ombudsman complaint posters are posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. 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. Residents have modified diets.

Incident Medical and Dental: Centrally stored resident medications were reviewed. 30-day supply of medications was observed. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Two (2) resident receives hospice services and two (2) resident receives home health services. No residents have prohibited health conditions. Bed rails, hoyer lifts, and special equipment are used by residents for mobility assistance.

Pursuant to Title 22, a citation was issued.

An exit interview was conducted with Administrator Thomas Thrice. A copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/18/2025 01:03 PM - It Cannot Be Edited

Created By: Noemi Galarza On 09/18/2025 at 12:32 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: EUROPEAN CHRISTIAN HOME V	FACILITY NUMBER: 198603568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 room #1 had an oxygen tank in the room but no signs of "No Smoking-Oxygen in Use" signs were observed outside the resident room door or in appropriate areas, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2025
	Plan of Correction
1 2 3 4	Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted when oxygen tanks are in the facility. Facility staff printed a sign and posted it outside room #1. *Cleared during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:

	Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC809 (FAS) - (06/04)

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