197609708-7-14-2025-31-AS-ERIS-DJKW5U-20250714165944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609708
Report Date: 07/14/2025
Date Signed: 07/14/2025 04:59:54 PM

Document Has Been Signed on 07/14/2025 04:59 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 LLC		FACILITY NUMBER:	197609708
ADMINISTRATOR/ DIRECTOR:	CALKO, JURATE EVA		FACILITY TYPE:	740
ADDRESS:	2851 W.AVENUE J9		TELEPHONE:	(661) 471-8803
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 3		CENSUS: 2	DATE:	07/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Jurate Eva Calko		TIME VISIT/ INSPECTION COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Evelin Rios conducted a required unannounced annual visit at this facility. LPA met with the administrator Eva Calko who granted access and LPA explained the purpose of the visit. A tour of the physical plant was conducted at approximately 01:40 p.m., with the administrator and the following was observed: Upon entry LPA observed appropriate postings along a wall by the front 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. Food that was opened and stored in tupperware was properly labeled. Food storage and preparation areas were clean. LPA observed all knives and sharp objects, locked in a kitchen cart drawer inaccessible to residents in care. There is one (1) fire extinguisher located by the kitchen, observed fully charged with service date 06/20/2025. 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 the couch, recliners and dinning table sits the capacity of the facility. 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. (Continue to LIC809-C)

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 07/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
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: 07/14/2025

NARRATIVE

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Bedrooms: LPA inspected three (3) resident bedrooms. Three (3) out of three (3) bedrooms are for private use. LPA observed occupied rooms to be properly furnished with beds, appropriate night stand, chair, bedding and have sufficient lighting and storage.

Bathrooms: The facility has two (2) bathrooms. One (1) is for residents' use. LPA observed resident bathroom to be clean and properly supplied with hand soap, toilet paper, and paper towels. LPA observed a non skid shower mat and proper grab bars by shower and toilet. At 3:28 p.m., LPA tested the hot water temperature in the residents' bathroom and it read 118.4 degrees Fahrenheit, within regulation.

Laundry: The laundry room is accessible to residents and leads to the garage. The garage is maintained locked. The facility keeps detergents and cleaning supplies locked in a cabinet in the laundry room.

LPA observed the administrator test a smoke detector at 3:26 p.m. Smoke detectors are interconnected located through out the facility. LPA observed detectors functioning properly. LPA observed fire doors close automatically when smoke detector was tested. LPA observed auditory door alarms on exit doors, on and functioning properly. LPA observed one (1) carbon monoxide detector and it was functioning properly.

Resident/Staff Records: At approximately 1:58 p.m., LPA reviewed two (02) of two (02) resident records for compliance with licensing forms. Review of records revealed one (01) of two (02) residents was recently admitted to hospice on 01/22/25, but a reappraisal was not documented. According to administrator resident#1's (R1's) change in condition and assessment was based on Hospice evaluation. At 2:33 p.m., LPA reviewed two (02) staff records to insure compliance with licensing forms and to verify up-to-date training. Administrator will send an email to Guardian Background Check System and include LPA regarding application for administrator's family member residing in the facility. Centrally stored medications are maintained locked in a hallway closet. Centrally Stored Medication and Destruction Records were reviewed. Facility keeps written records and Medication Administration Records (MARs).

Technical Violations issued (refer to LIC9102). Exit Interview Conducted. A copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC809 (FAS) - (06/04)

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