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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609708
Report Date: 08/21/2024
Date Signed: 08/21/2024 02:19:07 PM

Document Has Been Signed on 08/21/2024 02:19 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EVA'S CARE HOME IN LANCASTER LLCFACILITY NUMBER:
197609708
ADMINISTRATOR/
DIRECTOR:		CALKO, JURATE EVAFACILITY TYPE:
740
ADDRESS:2851 W.AVENUE J9TELEPHONE:
(661) 471-8803
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 3CENSUS: 3DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jurate Eva CalkoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced One (1) year Required visit at this facility. LPA met with the administrator Eva Calko who granted access and LPA explained the purpose of the visit. This is a single story home with three (3) bedrooms for resident use and two (2) bathrooms with an approved fire clearance for two (2) non ambulatory and one (1) bedridden resident for a total capacity of 3 residents.

Upon entry LPA observed administrator was preparing medications and updating Medication Administration Records (MARs) for morning medication and to add medication that was delivered. One staff#1(S1) was attending to the residents while administrator was documenting medication information.

A tour of the physical plant was conducted at 09:39 a.m. with the administrator and the following was observed: There is only one entrance being utilized at the facility, there are required postings posted by the main door.

Kitchen: LPA conducted a tour of the kitchen and observed there to be a sufficient supply of two day perishables and seven day non-perishable foods, properly stored. Food storage and preparation areas are clean. LPA observed all knives and sharp objects, locked in a kitchen cart inaccessible to residents in care. There is one (1) fire extinguisher located in the kitchen observed to be fully charged with service date 06/26/2024. LPA observed the first aid kit in a kitchen cabinet.
Common areas: LPA observed the living area and dining area to be clean. The furniture was in good repair and sits the capacity of the facility.
Bedrooms: LPA inspected three (3) resident bedrooms. Three (3) out of three (3) bedrooms are for private use. LPA observed each resident room to be properly furnished with beds, appropriate night stand, chair, bedding and with sufficient lighting and storage.

(Continue to LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EVA'S CARE HOME IN LANCASTER LLC
FACILITY NUMBER: 197609708
VISIT DATE: 08/21/2024
NARRATIVE
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LPA observed the administrator test a smoke detector at 9:58 a.m. Smoke detectors are interconnected located through out the facility. LPA observed detectors functioning properly. LPA observed door alarms on exit and entry doors on and functioning properly. LPA tested one (1) carbon monoxide detector and it appeared to be functioning properly.

Bathrooms: The facility has two (2) bathrooms. One (1) is located in the staff's private bedroom. LPA observed resident's bathrooms to be clean and properly supplied with hand soap, toilet paper, paper towels and a trash bin with a lid. LPA observed a non skid shower mat and proper grab bars by shower and toilet. LPA tested the hot water temperature in the resident's bathroom and it read 115.3 degrees Fahrenheit at 10:03 p.m.
Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for residents to use. There are no bodies of water.
Resident/Staff Records: At approximately 10:40 a.m. LPA reviewed resident and staff records to insure compliance with licensing forms. LPA observed a full bed rail on Resident #2's (R2's) bed. LPA's review of R2's records revealed R2 has an order for a bed rail but it does not specify the length and R2 is not receiving hospice care services so therefore R2's bed should not have a full length bed rail. Administrator informed LPA, R2 is a fall risk and a full bed rail is a precaution. Review of R2's physician's report revealed a diagnosis of Dementia and that it was completed on 05/06/2023. Administrator informed LPA they would work with R2's family to schedule a doctors appointment to conducted an updated medical assessment. Review of three (3) staff records revealed S1 has not been finger printed and did not poses a background clearance prior to working at this facility. Administrator admitted they are still waiting for S1 to complete required documentation. Upon further review administrator failed to obtain a copy of S1's health screening as well.
Medications: Centrally stored medications are maintained locked in a kitchen cabinet. Centrally Stored Medication and Destruction Records were reviewed. Facility keeps written records and Medication Administration Records (MARs).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during todays visit (refer to LIC809-D). Exit Interview Conducted. Appeal rights provided. A copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/21/2024 02:19 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/21/2024 at 01:29 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: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

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 one (1) out of three (3) staff not finger printed for background clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Licensee will not allow S1 to return to work until fingerprints are submitted for background clearance. Once complete Licensee will inform LPA once S1 is on Guardian Background Check System cleared and associated to this facility.
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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/21/2024 02:19 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/21/2024 at 01:29 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: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee will provide copies of staff's health screening along with TB test results to LPA by POC due date 09/13/2024.
Section Cited
Personnel Records
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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/21/2024 02:19 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/21/2024 at 01:29 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: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 resident #2(R2) having a full length bed rail even though they are not receiving Hospice services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee informed LPA they will submit a request for an exception as resident is a fall risk. LPA informed Licensee facility must be in compliance while they seek an exception. Licensee will remove full length bed rail and request half rail while exception letter is reviewed.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R2, a resident with dementia not having an annual medical assessment completed timely, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee informed LPA they will work with R2's family to schedule a doctors appointment for R2 for an updated medical assessment. Licensee will submit a copy of R2's updated physician's report/medical assessment to LPA by POC due date 09/13/2024.
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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
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