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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604108
Report Date: 08/03/2021
Date Signed: 08/03/2021 05:51:18 PM

Document Has Been Signed on 08/03/2021 05:51 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PERPETUAL HELP HOME CAREFACILITY NUMBER:
374604108
ADMINISTRATOR:RAMIREZ, JOSE & HELENFACILITY TYPE:
740
ADDRESS:29531 MACTAN RDTELEPHONE:
(709) 913-5580
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 6CENSUS: 6DATE:
08/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jose Ramirez, AdministratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced Case Management visit on today's date regarding an Incident Report received by CCLD on August 2, 2021 for Resident #1 (R1) (See LIC 811 - Confidential Names List). LPA Hamer arrived at the facility and was greeted at the entrance by Caregiver Rolly DeGuzman. Then, LPA identified himself and disclosed the purpose of this visit which was to follow up on the Incident Report reporting the AWOL of R1. Administrator Jose Ricardo Ramirez later arrived at the facility and met with LPA.

The Incident Report submitted to CCLD is dated August 2, 2021 and was submitted by Mr. Ramirez. The report reveals that R1 left the facility on July 31, 2021 and that, according to R1’s Physician’s Report, they can leave the facility unassisted. LPA Hamer reviewed pertinent information from R1’s file and received copies of facility records from the administrator, including records from R1’s file. LPA also reviewed the facility’s Absentee Notification Plan and the administrator also provided a copy to LPA.

During the tour of the facility, when LPA walked into the kitchen, LPA observed and took pictures of several knives and other sharp objects accessible to a resident in care with dementia who was present in the kitchen area prior to LPA's arrival. LPA also observed and took pictures of cleaning supplies, including bleach and window cleaner, in two (2) unlocked cabinets in the kitchen area, both violations of California Code of Regulations, Title 22, Division 6, Chapter 8.
(continued on LIC 809C)
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Adam Hamer
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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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Document Has Been Signed on 08/03/2021 05:51 PM - It Cannot Be Edited


Created By: Adam Hamer On 08/03/2021 at 03:09 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PERPETUAL HELP HOME CARE
FACILITY NUMBER: 374604108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2021
Section Cited
CCR
87705(f)(1)

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87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia:Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Adminstrator immediately removed the knives and other sharp objects and placed them inside of a locked drawer.
Type A
08/03/2021
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia:Over-the-counter medication,nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Administrator immediately removed the cleaning supplies from the unlocked kitchen cabinets and placed them in a locked laundry room.
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This requirement was not met as evidenced by LPA observation and interview with Administrator. Licensee did not ensure that knives, sharp objects and cleaning supplies that were stored were inaccessible to residents in care. This posed an immediate safety risk to 1
out of the 6 residents in care.
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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:Denise Powell
LICENSING EVALUATOR NAME:Adam Hamer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021


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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PERPETUAL HELP HOME CARE
FACILITY NUMBER: 374604108
VISIT DATE: 08/03/2021
NARRATIVE
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LPA observed deficiencies during today's visit and citations are being issued as detailed on the attached LIC 809D. An exit interview was conducted with Mr. Ramirez. LPA reviewed this report, the attached LIC 809D, including the administrator's plan of correction, the LIC 811 and Licensee / Appeal Rights (LIC 9098 01/16) with Mr. Ramirez. The documents were also emailed to Mr. Ramirez and he expressed to LPA that he would send a confirmation upon receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Adam Hamer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC809 (FAS) - (06/04)
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