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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001947
Report Date: 11/02/2023
Date Signed: 11/02/2023 05:24:59 PM


Document Has Been Signed on 11/02/2023 05:24 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: 3DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Eva Nemethy, Administrator TIME COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Eva Nemethy, Administrator, and Robert Kovacs, caregiver, and explained purpose of inspection. LPA observed (2) residents to be in their rooms at the start of the inspection and (1) resident return during the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (6). Currently, there are (0) residents on hospice. LPA printed an updated license to reflect an approved hospice waiver for (6).

LPA and the Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms (3), kitchen, staff room and laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, soap and 20-second hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and toxins in the kitchen and locked medications and additional toxins in the laundry room. LPA observed the inside temperature to be 68*F.

LPA observed (1) unlocked gate from the inside back patio. There are no bodies of water or a pool. LPA observed sufficient incontinent products and PPE on hand. The hot water temperature measured 112*F in a guest bathroom and 120* F in the kitchen. The facility conducts quarterly fire drills. LPA reviewed (3) of (3) resident files and found them to contain the required paperwork and updated care plans. LPA reviewed (2) staff files and discussed staff training for (S1) and (S2) who do not have current First Aid/CPR on file and for (S1) who has not completed the required (20) hours of annual training. (2) citations are issued during today's inspection.

LPA reviewed the Infection Control Plan and found it to be complete and address all required areas.
LPA will return at a near date in the future to complete the annual inspection.

Exit interview. Copy of report and appeal rights provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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 11/02/2023 05:24 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: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625
Staff training; legislative findings; contents
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in (1) out of (3) staff persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Licensee/Administrator agrees to have staff (S1) complete the required (20) hours of annual training and provide documentation to the Department by 11/17/23.
Type B
Section Cited
HSC
1569.618
ยง1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling.

(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 interviews and record review, the licensee did not comply with the section cited above in (2) out of (3) staff persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Licensee/Administrator agree to ensure that staff (S1) and (S2) complete First Aid and CPR certification and submit documentation to the Department by 11/17/23.
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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2