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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412271
Report Date: 08/14/2024
Date Signed: 08/14/2024 12:11:35 PM


Document Has Been Signed on 08/14/2024 12:11 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ERWIN LAKE ELDERLY CAREFACILITY NUMBER:
366412271
ADMINISTRATOR:YVONNE KURZEJAFACILITY TYPE:
740
ADDRESS:2052 STATE LANETELEPHONE:
(909) 585-4004
CITY:BIG BEAR CITYSTATE: CAZIP CODE:
92314
CAPACITY:6CENSUS: 2DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Administrator Yvonne KurzejaTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Sarina Ramirez and LPM Karen Clemons made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Yvonne Kurezeja, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6), a current census of (2) residents in care and a hospice waiver for (4). LPA Ramirez conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor shaded area is sufficient for resident activities and is enclosed with self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating carbon monoxide alarms and telephone service. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary conditions. The hot water temperature in both resident bathrooms measured 110 and 112 degrees F. Three (3) resident’s bedrooms had beds, bed linen, chairs, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, facility license, disaster evacuation plan and emergency telephone numbers.

Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care.

Continuation on LIC 809-C:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ERWIN LAKE ELDERLY CARE
FACILITY NUMBER: 366412271
VISIT DATE: 08/14/2024
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Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training.

Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. The facility has sufficient first aid supplies.

Record Review: The Administrator's certification is current. The facility’s last fire drill was conducted on 7/7/24. Five (5)Staff files reviewed were observed to be complete. Two (2) Resident files reviewed were observed to be complete.

Based on observations and record review, no technical violations or deficiencies will be cited per Title 22, of The California Code of Regulations.

An exit interview was conducted where the Licensing reports were discussed and copies were provided to Administrator Yvonne Kurezeja.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Sarina RamirezTELEPHONE: (951) 248-0307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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