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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609708
Report Date: 07/02/2021
Date Signed: 07/02/2021 11:35:32 AM

Document Has Been Signed on 07/02/2021 11:35 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EVA'S CARE HOME IN LANCASTER LLCFACILITY NUMBER:
197609708
ADMINISTRATOR:CALKO, JURATE EVAFACILITY TYPE:
740
ADDRESS:2851 W.AVENUE J9TELEPHONE:
(661) 471-8803
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 2CENSUS: 2DATE:
07/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Jurate Eva Calko/ AdministratorTIME COMPLETED:
11:49 AM
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Licensing Program Analyst (LPA) Patrick Shanahan conducted an Annual Required visit and inspection of the facility. LPA met with the facility administrator and explained the reason for the visit.

A tour of the physical plant was conducted. All smoke alarms were tested and function properly. The fire extinguisher was last serviced on 4/14/2021. The carbon monoxide detector was tested and functions properly. New fire doors were installed and were activated once the alarms were tested. A doorway for the office was enclosed and the facility has requested for a capacity increase.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and detergents were stored in locked drawers and cabinets. Properly labeled medications were locked in a cabinet near the kitchen. Bedrooms: There were 2 bedrooms designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There is one bathroom designated for residents' use. Bathroom was clean, properly supplied and had functional fixtures. Hot water temperature was 113.6 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, No Deficiencies were cited Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2021
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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