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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603754
Report Date: 07/22/2022
Date Signed: 07/22/2022 10:59:57 AM


Document Has Been Signed on 07/22/2022 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:EAGLES NEST ELDERCARE HOMES IIFACILITY NUMBER:
374603754
ADMINISTRATOR:CALHOUN, CHERRYFACILITY TYPE:
740
ADDRESS:1364 GREENWAY RISETELEPHONE:
(760) 294-3306
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 4DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kevin Calhoun, LicenseeTIME COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by caregiver, Jonathan Ramos who was informed of the purpose of the visit. Jonathan called Licensee, Kevin Calhoun who arrived at the facility shortly after. At the time of visit there was 2 staff and 4 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility inside and out with Kevin Calhoun and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. LPA did not observe any pools or bodies of water within the premises. LPA was informed that no weapons or ammunition is maintained at the home. No annual fees due.

The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident's physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies.

During the tour of the kitchen, LPA observed kitchen knife laying on the kitchen countertop and dish cleaning supplies under the sink not adequately secured. Upon review of residents file, LPA discovered two residents are diagnosed with dementia. Citation will be issued.

Based on the observations made during today’s visit, two (#2) deficiencies were cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and a copy of this report was reviewed and provided along with appeal rights to Kevin Calhoun.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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 07/22/2022 10:59 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: EAGLES NEST ELDERCARE HOMES II
FACILITY NUMBER: 374603754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Kevin Calhoun stated that he will submit a written statement of understanding of the regulation cited above by the POC due date 8/1/2022.
Deficiency Dismissed
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Kevin Calhoun stated that he will submit a written statement of understanding of the regulation cited above by the POC due date 8/1/2022
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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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