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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603864
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:04:19 PM

Document Has Been Signed on 07/03/2024 01:04 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 INCFACILITY NUMBER:
374603864
ADMINISTRATOR/
DIRECTOR:		CALHOUN, KEVINFACILITY TYPE:
740
ADDRESS:1983 DREW RDTELEPHONE:
(760) 755-7423
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 5DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:Carizaa Bawiin, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 07/03/24, Licensing Program Analyst (LPA), Javina George made an unannounced visit to the facility to conduct the required annual inspection. LPA met with Caregiver Clarizza Bawiin and Administrator, Kevin Calhoun via telephone as he was unable to come to the facility. LPA explained the purpose of the visit. At the time of the visit there were 2 staff and 5 residents present. The home is licensed to serve age range 60 and over, 6 non-ambulatory of which 6 may be bedridden. The facility has an approved hospice waiver for 4. There are currently 3 residents receiving hospice services.

The facility was observed to be clean, clutter and odor free. Outdoor and indoor passageways are free of obstruction. The facility is a single story consisting of (5) bedrooms, and (3) bathrooms, kitchen, living room, backyard, and garage. The restrooms were equipped with grab bars and non skid mats.

The facility food supply met the requirements as there is a 7 day supply of non perishables, and a 2 day supply of perishable food items. The fire extinguisher was observed to be fully charged, with tag in tact. Carbon monoxide and smoke detectors were tested and were observed to be operable.

The facility was observed to have the required postings such as Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area.

LPA conducted a records review of 5 resident and 4 staff files. The files were found to have the required documentation, staff were observed to have obtained criminal record clearance. Per the records review 2 of 2 staff did not possess a valid CPR certification. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8), on the attached 809D.

An exit interview was conducted and a copy of this report, appeal rights and LIC9098-Proof of Corrections form was reviewed and provided to the Clarizza Bawiin, Caregiver.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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 07/03/2024 01:04 PM - It Cannot Be Edited


Created By: Javina George On 07/03/2024 at 12:32 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 INC
FACILITY NUMBER: 374603864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 2 out of 2 persons, as S1 and S3, do not possess a valid CPR certification, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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The Licensee agrees to have S1 and S3 enroll and then complete CPR certification training. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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