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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604108
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:31:05 PM

Document Has Been Signed on 02/19/2025 03:31 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PERPETUAL HELP HOME CAREFACILITY NUMBER:
374604108
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, JOSE & HELENFACILITY TYPE:
740
ADDRESS:29531 MACTAN RDTELEPHONE:
(760) 913-5580
CITY:VALLEY CENTERSTATE: CAZIP CODE:
92082
CAPACITY: 6CENSUS: 6DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jose and Helen Ramirez, Administrator's TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 02/19/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Caregiver Elvira Mangabat, the Administrator's Jose and Helen Ramirez arrived shortly after. The facility has an approved hospice waiver for (1) with (0) residents currently receiving hospice services. At the time of the visit there was (3) staff and (6) residents present. LPA verified the contact information for the facility that is on file with the department.
LPA conducted a tour of the interior and exterior and upon exiting the car there was an odor of sewage outside per Administrator there is a clog with the line, and someone is due to come out and service it tomorrow 2/20/25. The administrator agreed to show proof of service to the department no later than 5pm on Friday 02/21/25. The facility was observed to have running water, and the smoke and carbon monoxide detectors were observed to be operable. The facility was observed to have several cob webs throughout the facility in the window sills, in the hallway hanging from fixtures. The medications were observed to be locked inside a closet inside the hallway by the kitchen. LPA observed for there to be (3) bottles of liquid medication and (1) vile of liquid medication, that was siting in a small box on table inside the hallway. The medication was moved and locked in the closet during the visit. Emergency disaster drills are being conducted on a quarterly basis, the last drill was conducted on 01/29/25. The facility has pool that is drained, there is a fully charged fire extinguisher. There are no known guns or ammunition on the premises. File review: The administrator's Jose and Helen did not have their files available to review at the time of the inspection. In addition there was no staff present with valid CPR certification, deficiencies cited. Resident files had the appropriate assessments and appraisals as well as admissions agreements. All staff present had criminal record clearance and were observed to be associated to the facility. The facility had a sufficient food supply 2 days of perishables and 7 days of non perishable food items. Based on today's inspection a citation will be issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, appeal rights, LIC9098-Proof of Corrections form and LIC 811- Confidential names list was provided to Helen Ramirez.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 3
Document Has Been Signed on 02/19/2025 03:31 PM - It Cannot Be Edited


Created By: Javina George On 02/19/2025 at 03:11 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PERPETUAL HELP HOME CARE
FACILITY NUMBER: 374604108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 persons as S1 and S2 And S3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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The licensee agrees to enroll and have staff identified to complete CPR certification. Proof is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/19/2025 03:31 PM - It Cannot Be Edited


Created By: Javina George On 02/19/2025 at 03:11 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PERPETUAL HELP HOME CARE
FACILITY NUMBER: 374604108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in 2 out of 2 persons as they administrator's did not have their file available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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The licensee agrees to create an employee file for the facility, proof is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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