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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426751
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:38:40 PM

Document Has Been Signed on 11/06/2024 03:38 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 CAREFACILITY NUMBER:
366426751
ADMINISTRATOR/
DIRECTOR:
EVANS, KELLYFACILITY TYPE:
740
ADDRESS:13947 CASTILLE ST.TELEPHONE:
(760) 261-4241
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Kelly Evans-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Kelly Evans and introduced self and stated purpose of the visit. LPA was informed that there is 1 resident 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 72 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 108.2 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. 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. LPA observed that the facility's living room, kitchen and dining areas were not clean. Deficiency issued.

Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.

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.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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Document Has Been Signed on 11/06/2024 03:38 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: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not having an active liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator stated that she will purchase a liability insurance and submit proof to LPA via email by POC due date.
Section Cited
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by not having a clean kitchen, dining areas and living room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Administrator stated that she will clean the kitchen, dining areas and living room. Administrator stated that she will submit a statement of understanding 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.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 03:38 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: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not having the administrator's file available for audit with a current health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator stated that she will submit a copy of the administrator's file with a current health screening to LPA via email by POC due date.
Section Cited
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not renewing their administrator's certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator stated that she will renew her administrator's certificate and show proof of process 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.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 03:38 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: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not conducting quarterly emergency drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator stated that she will conduct a drill and submit proof to LPA along with a statement of understanding on the regulation cited via email by POC due date.
Section Cited
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
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Based on observation, interview, and record review, the administrator did not comply with the section cited above by reviewing/updating the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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Administrator stated that she will review/update the emergency disaster plan annually and submit proof 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.
Nedra BrownTELEPHONE: (951) 202-5776
Michelle EcheverriaTELEPHONE: 951-248-0345

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: EVANS ELDERLY RESIDENTIAL CARE
FACILITY NUMBER: 366426751
VISIT DATE: 11/06/2024
NARRATIVE
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Record Review: LPA reviewed staff and administrator file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed that the administrator's file was not available for audit. Deficiency issued. LPA observed that the facility did not renew the Administrator Certificate Requirements. Deficiency issued. LPA reviewed resident file for admission agreements, updated physician reports, and needs and services plans. LPA observed through record review and interview that the facility did not have a liability insurance. Deficiency issued. LPA observed that the facility did not have a record of disaster drills conducted quarterly. Deficiency issued. LPA observed that the facility has not reviewed/updated the emergency disaster plan annually. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D,and appeal rights were discussed and copies were provided to Administrator, Kelly Evans.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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