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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609708
Report Date: 06/27/2022
Date Signed: 06/28/2022 04:41:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/28/2022 04:41 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: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: 3CENSUS: 2DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eva CalkoTIME COMPLETED:
01:25 PM
NARRATIVE
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At 12:00 p.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA observed covid-19 signage posted outside the facility. LPA was greeted by a staff member and granted access to the facility. Staff did not screen LPA for covid-19. LPA met the Administrator Eva Calko and an entrance interview was conducted. The purpose of the visit was explained.

At 12:15 p.m., LPA initiated a physical plant tour. This is a four (4) bedroom two (2) bathroom Residential Care Facility for the Elderly. Sufficient PPE supplies were observed. The fire extinguisher has a date of service of April 13, 2022. Smoke detectors and carbon monoxide monitors were observed to be functional. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. At 12:25 p.m., LPA observed sharps, cleaning supplies and medications unlocked and accessible to residents in care. Extra towels and linens were readily available. Bathrooms have soap, paper towels and trash cans with lids. Bedrooms are clean and have appropriate furniture. The backyard is clean, has various covered shaded areas. No bodies of water.

Deficiencies issued pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations. Exit interview conducted and a copy of the report was signed and delivered.
(cont. on 809-D)
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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 06/28/2022 04:41 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 06/28/2022 at 04:36 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: EVA'S CARE HOME IN LANCASTER LLC
FACILITY NUMBER: 197609708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2022
Section Cited
CCR
87470(c)(1)(F)

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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.
This requirement was not met as evidenced by:
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Licensee shall ensure all staff will attend infection control training to be provided by an individual trained in infection control. Proof of training shall be signed by each staff and submitted by the POC due date of 6/29/2022.
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Based on observations the licensee did not comply with the cited section by not screening LPAs for symptoms of COVID 19 upon entry and staff where not wearing masks, which poses and immediate Health and Safety and personal rights risk to persons in care.
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Type A
06/29/2022
Section Cited
CCR87705(f)(1)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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The Administrator has locked all the sharps and medications. This part of the plan of correction was met during the visit. The Administrator has agreed to provide training to all staff on the importance of maintaining medications, sharps and chemicals inaccessible and the administrator shall submit staff sign in sheet with the topic and the training material.
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Based on observation, the licensee did not comply with the section cited above. LPA observed sharps, medication and cleaning supplies to be accessible to residents in care which poses and immediate Health and 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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