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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604108
Report Date: 03/17/2025
Date Signed: 03/17/2025 10:09:38 AM

Document Has Been Signed on 03/17/2025 10:09 AM - 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: 5DATE:
03/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:Elvira Mangabat, Caregiver TIME VISIT/
INSPECTION COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit. LPA requested the file for Resident #1 (R1) and was informed that there was no file at the facility due to R1 being discharged. LPA was unable to review the file requested. Deficiency cited.

Based on today's visit a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8) on the attached 809D.

An exit interview was conducted and a copy of this report, appeal rights, LIC9098-Proof of Corrections form and LIC811-Confidential names list was reviewed and provided to Elvira Mangabat, Caregiver.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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Document Has Been Signed on 03/17/2025 10:09 AM - It Cannot Be Edited


Created By: Javina George On 03/17/2025 at 09:52 AM
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: 03/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87506(e)

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87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: R1s resident file was not at the facility, or brought to the facility
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The licensee agrees to provide the full file, including MARs for C1 for LPA to review. The file can be emailed and scanned, or copies dropped at the regional office. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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 for LPA to review during today's visit, which poses a potential health, safety and personal rights risk to persons 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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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