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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001947
Report Date: 08/10/2023
Date Signed: 08/10/2023 01:46:46 PM


Document Has Been Signed on 08/10/2023 01:46 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:EVA'S CARE HOMEFACILITY NUMBER:
347001947
ADMINISTRATOR:NEMETHY, EVAFACILITY TYPE:
740
ADDRESS:8220 CATALPA DRIVETELEPHONE:
(916) 727-1904
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 2DATE:
08/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Robert Kovacs, caregiver TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Robert Kovacs, caregiver, and explained purpose of inspection. Caregiver indicated that Ombudsman was just at the facility to follow up on the same resident (R1). LPA spoke with Eva Nemethy, Administrator, by phone who stated she was currently at a medical appointment. LPA stated the reason for the inspection and discussed resident (R1).

Both the caregiver and Administrator indicated resident (R1) has shown a decline in recent months, especially with his appetite, and has refused medical treatment on several occasions when 9-1-1 was called. Most recently, resident was vomiting a white mucous. LPA observed a note signed by resident on 8/4/23 refusing medical care. After speaking again with resident's primary care physician and nurse, 9-1-1 was called by the nurse this time, and resident agreed to be taken to the emergency room for a medical evaluation on 8/8/23. The facility has been in contact with the hospital staff and was informed resident has been diagnosed with a Urinary Tract Infection (UTI) and may return to the facility as early as tomorrow, 8/11/23. Caregiver stated that resident has received bed baths over the last couple of months but will also take a shower with assistance. Resident also wanted a walker to be nearby the bed when needed.

LPA reviewed resident's file and observed a physician's report from 2019 when resident was admitted. Resident does not have a diagnosis of Dementia. LPA discussed with the Administrator how only the initial care plan was found in the file and how the care plan must be updated at least every 12 months, or when there is a change in condition, such as what she and caregiver have described with R1 over the past 6-7 months. Administrator agreed to submit an updated plan for R1 within 2 weeks. LPA reviewed resident files for the other (2) residents and found them to contain required paperwork. LPA toured the inside of the home and did not observe any health/safety risks and found the facility to be clean, odor-free and in good repair.
Per California Code of Regulations, Title 22, Chapter 6, Division 6, the following (1) deficiency is cited on the 809-D page.
Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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 08/10/2023 01:46 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EVA'S CARE HOME
FACILITY NUMBER: 347001947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2023
Section Cited
CCR
87463(c)

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87463 Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
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Licensee/Administrator agree to complete and updated care plan (LIC625) for R1 and submit it to the Department by 8/24/23.

Licensee/Administrator agrees to read
Regulation 87463 and submit a signed statement that it is understood. Also due to Department by 8/24/23.
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Based on documentation reviewed and interviews conducted, the Licensee did not ensure that an updated care plan was completed for resident (R1) at least annually, in 2020, 2021, 2022 and in 2023, including when there was a change in condition over the past 6-7 months, which poses a potential health and safety risk to residents in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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