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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608907
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:36:49 PM

Document Has Been Signed on 05/27/2022 02:36 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INCFACILITY NUMBER:
197608907
ADMINISTRATOR:CELIA T. OYIBUFACILITY TYPE:
740
ADDRESS:44161 11TH ST. WTELEPHONE:
(661) 317-7354
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 3DATE:
05/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Charles OyibuTIME COMPLETED:
01:20 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit to investigate Complaint #31-AS-20220523171448. Upon arriving at the facility at 10:00 am, LPA observed the caregiver who greeted LPA at the front door was not wearing a mask.

LPA and Caregiver toured the facility from 11:40 until 12:00 noon. At 11:40 am, LPA and caregiver entered the kitchen. LPA asked the location of the knives and cleaning supplies in the kitchen. LPA observed the caregiver open the cabinet below the kitchen sink but noticed the lock that was placed on the cabinet was not locked. Caregiver opened the cabinet and LPA observed the cleaning supplies and knives were in the cabinet.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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
Document Has Been Signed on 05/27/2022 02:36 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 05/27/2022 at 12:20 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
87470(5)(b)(2)

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All staff and volunteers providing direct care to a resident....shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents...This requirement was not met as evidenced by:
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Administrator will conduct training for staff regarding infection control guidelines. Administrator will provide to LPA signature of staff members who participated in the training.
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Upon entering the facility, LPA observed staff member was not wearing a mask which poses an immediate health and safety risk to residents in care.
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Type B
05/27/2022
Section Cited
CCR87309(a)

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Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by;
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At 12:25 pm, LPA observed caregiver locked the cabinet. LPA stated staff need to ensure the cabinet is locked at all times.
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LPA observed the cleaning supplies were stored underneath the sink but the cabinet was not locked which poses an immediate health and safety risk to 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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


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