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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603656
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:17:16 PM

Document Has Been Signed on 06/19/2023 03:17 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 VIFACILITY NUMBER:
198603656
ADMINISTRATOR:TRICE, THOMASFACILITY TYPE:
740
ADDRESS:19208 SHERYL AVENUETELEPHONE:
(562) 397-2591
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 5DATE:
06/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Thomas TriceTIME COMPLETED:
03:31 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
On 6/19/2023 Licensing Program Analyst (LPA) Jewel Baptiste conducted a Pre-licensing inspection. LPA met with Thomas Trice, the licensee. An application was submitted to CCLD on 1/12/23 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, 6 of which may be non-ambulatory. There are currently 5 residents residing at the facility.

LPA inspected and observed the following:

Facility is a Two- story home which consists of 4 resident rooms, 2 bathrooms, 2 living room, dining area, kitchen. Upstairs consisted of a 2-bedroom, 1 bathroom loft/office. The spacious backyard with shaded area. 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.

All bedrooms are equipped with a bed, nightstand, chair, and adequate closet space. There is adequate lighting throughout the room. All bathrooms have a walk-in shower, non-skid matts, and shower chairs. 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 is sufficient food supply of 2-day perishable and a week of nonperishable on the premises.

(Continue on LIC809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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
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 VI
FACILITY NUMBER: 198603656
VISIT DATE: 06/19/2023
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
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. The medications are stored and locked in a cabinet. Staff and resident files are maintained at the facility.

The facility phone number is (562) 860- 0189.

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 provided to the applicant.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2