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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608907
Report Date: 09/01/2021
Date Signed: 09/01/2021 01:51:01 PM

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:COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INCFACILITY NUMBER:
197608907
ADMINISTRATOR:CELIA T. OYIBUFACILITY TYPE:
740
ADDRESS:44161 11TH ST. WTELEPHONE:
(661) 317-7354
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 5DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Charles OyibuTIME COMPLETED:
12:00 PM
NARRATIVE
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LPA Spaeth conducted an unannounced annual visit to the facility and arrived at 10:30 am. LPA was greeted by Charles Oyibu, staff member who was wearing a mask and requested LPA sign in. Staff member recorded LPA's temperature. LPA explained the purpose of the visit is to conduct a annual visit to the facility.

Staff member escorted LPA throughout the facility and LPA observed the COVID sign at the front door, the sign in station with thermometer, sign in sheet, and hand sanitizer. LPA was then escorted to the kitchen and observed the knives and cleaning supplies were locked underneath the sink. LPA observed an adequate supply of fresh vegetables and fruits in the refrigerator along with frozen meats. The pantry was stocked with canned goods. LPA was then escorted to the hallway and observed the medications were securely locked in a cabinet. LPA observed the bathroom which contained wash your hands sign, hand soap, paper towels and a trash can. LPA observed a 90 day supply of PPE which included masks, gloves, hand sanitizer and other items which were stored in a hallway closet. LPA observed the linens were also stored within the hallway closet.

LPA Spaeth observed a person mopping the floor and asked Staff member to identify the person in the facility. Staff member stated is a family member visiting the Administrator.
Pursuant to Title 22 California Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report along with the appeal rights provided to licensee.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited

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87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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This requirement is not met as evidenced by: Based on LPA Spaeth observing a individual in the facility mopping the floor, LPA was told the person was not a staff member and has been visiting for the past three weeks.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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