<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603754
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:06:37 PM

Document Has Been Signed on 04/25/2024 01:06 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:EAGLES NEST ELDERCARE HOMES IIFACILITY NUMBER:
374603754
ADMINISTRATOR/
DIRECTOR:		CALHOUN, CHERRYFACILITY TYPE:
740
ADDRESS:1364 GREENWAY RISETELEPHONE:
(760) 294-3306
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 5DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Kevin Calhoun, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility to conduct an annual inspection. LPA met with caregiver, Luis Galvan. Licensee Kevin Calhoun arrived shortly. LPA explained the purpose of the visit and was granted entry into the facility. Present at the facility were five (5) clients and two (2) staff. The facility is a one story, five (5) bedroom two (2) bathroom home. The facility was inspected inside and out.

LPA conducted staff and client interviews. Staff and client records were also inspected. Staff present have criminal record clearances and are appropriately associated to the facility. Client records contain current and appropriate documents. The facility appears clean and free of odors. Client bedrooms are clean and appropriately furnished. Food supplies are sufficient. LPA observed all toxic chemicals and other hazards secured and inaccessible to clients. Water temperature was measured and deemed appropriate at 117 degrees. Fire extinguishers are in working order. Smoke and Carbon Monoxide alarms were tested and operable. Furniture in the facility is in good repair. Outdoor space is free of hazards. Drills are conducted regularly. Required signage are posted throughout the facility.

LPA inspected medications and during the inspection, the LPA observed the following deficiency:



-The facility had medication pills that were pre-prepared and stored in a cup - not in its original container. LPA advised staff present medication must remain stored in it's original container and not in pill cups. Citation issued.

An exit interview was conducted and a copy of this report was provided along with the LIC 809D, LIC 811 and a copy of Appeal Rights.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 2
Document Has Been Signed on 04/25/2024 01:06 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 04/25/2024 at 12:26 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EAGLES NEST ELDERCARE HOMES II
FACILITY NUMBER: 374603754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, medication for PM distribution were observed to be stored in pill cups. The licensee did not comply with the section cited above in [5] out of [5] persons) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
1
2
3
4
Licensee will review the regulation cited above and will provide additional training to staff regarding medication storage. Licensee will submit a letter to the Department documenting date, time and signatures of staff who received the training.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


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