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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608907
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:00:05 PM


Document Has Been Signed on 09/29/2022 04:00 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: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: 2DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Charles OyibuTIME COMPLETED:
01:00 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
LPA Spaeth an unannounced visit and was greeted by caregiver. LPA observed caregiver was wearing a mask. LPA's temperature was taken and COVID questions. LPA observed the sign in station at the entrance of the facility. Caregiver stated there are two residents living in the facility. LPA observed comfortable seating in the family room and a dining room table within the dining room section of the facility.

LPA observed the resident bedrooms contained bed, linens, night stand, and lamp. LPA observed the outside area contained comfortable seating and the side gate leading to the front yard was not locked. LPA observed the residents' medications were locked in a hallway closet. The closet also contained additional PPE.

There are two bathrooms in the facility and both contained slip resistant mat, hand soap, paper towels, and a trash can. The smoke detectors were tested at 11:00 am and were properly working. Also, LPA observed fresh linens in a hallway closet.

Upon entering the kitchen, LPA observed a seven day supply of canned goods and a two-day supply of fresh vegetables and fruits in the refrigerator. The freezer section of the refrigerator contained frozen meats. LPA observed hand soap at the kitchen sink. LPA observed the kitchen cabinet beneath the sink was not locked. The cleaning supplies were located in the cabinet. LPA observed the cabinets above the washer and dryer were not locked which contained the laundry detergent. A deficiency was observed and is hereby cited. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to caregiver.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 09/29/2022 04:00 PM - It Cannot Be Edited

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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited

1
2
3
4
5
6
7
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on observations made during LPA's annual visit, the cleaning supplies underneath the kitchen sink and washing detergent in the laundry room were not locked which poses a potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2