366426751-11-7-2023-56-AS-MECA-CXCS4B-20231107123227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426751
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:32:39 PM

Document Has Been Signed on 11/07/2023 12:32 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	EVANS ELDERLY RESIDENTIAL CARE		FACILITY NUMBER:	366426751
ADMINISTRATOR:	EVANS, KELLY		FACILITY TYPE:	740
ADDRESS:	13947 CASTILLE ST.		TELEPHONE:	(760) 261-4241
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 2	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Kelly Evans-Administrator		TIME COMPLETED:	12:40 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	On 11/07/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with caregiver, Billie Darthard and introduced self and stated purpose of the visit. LPA was informed that there are 2 residents in care. The facility has 4 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, family room, office, laundry, backyard, and attached garage. LPA completed a walk through of facility and review of records with Administrator, Kelly Evans. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 106.4 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher and first aid kit. Posters such as; the personal rights, emergency disaster plan, and ombudsman were posted in a common area. LPA observed an outdated emergency disaster plan last reviewed on 10/09/2015. Deficiency issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications was observed locked and inaccessible to residents. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 11/07/2023 12:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVANS ELDERLY RESIDENTIAL CARE	FACILITY NUMBER: 366426751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above in hiring staff with criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2023
	Plan of Correction
1 2 3 4	Administrator removed staff immediately from premises. Administrator stated that she will have staff get criminal record clearance and submit proof to LPA via email as soon as it's cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/07/2023 12:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVANS ELDERLY RESIDENTIAL CARE	FACILITY NUMBER: 366426751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)(1)(D)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in maintaining an updated Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will create and update an Infection Control Plan and submit a copy via email to LPA by POC due date.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in including a signed personal rights form for each resident and emergency ID form for one resident which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will have residents sign a personal rights form and include a emergency ID form for one resident. Administrator stated that she will submit a copy to LPA via email by POC due date.

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 11/07/2023 12:32 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVANS ELDERLY RESIDENTIAL CARE	FACILITY NUMBER: 366426751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the administrator did not comply with the section cited above in reviewing the emergency disaster annually which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Administrator stated that she will review and update the emergency disaster plan and submit a copy to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: EVANS ELDERLY RESIDENTIAL CARE	FACILITY NUMBER: 366426751
	VISIT DATE: 11/07/2023

NARRATIVE

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Yards/Outside: One shaded patio, side gate with self-latching handle on the left and right side of the house that leads into the backyard.

Record Review: LPA reviewed staff and administrator file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed no criminal record clearance for present staff. Deficiency with civil penalty issued. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed incomplete files for residents. Deficiency issued. LPA observed that the facility did not have an updated infection control plan. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and appeal rights were discussed and copies were provided to Administrator, Kelly Evans.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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