Eva's Care Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection regarding a death report recently submitted to the Department. LPA met with caregiver, Robert Kovacs, and explained purpose of inspection. Administrator, Eva Nemethy, was contacted by phone. LPA and the caregiver discussed the recent passing of prior resident (R1) on June 19, 2026, who was not under hospice care. The caregiver stated that (R1) had been declining for several months, and the decline was reported to the administrator, and (R1's) health care provider. The caregiver described (R1's) decline to include a decline in appetite, episodes of vomiting and more frequent diarrhea. The caregiver stated that (R1's) health care provider indicated the diarrhea could be a reaction to medication changes. The caregiver stated that he contacted 9-1-1 on June 16, 2026 due to (R1) showing these symptoms, and (R1) was discharged back to the facility later in the day, in the same condition. Both the administrator and caregiver confirmed, (R1) saw a physician from their primary care group on June 15, 2026 and lab tests were ordered. LPA reviewed the hospital discharge papers which note (R1) was seen for vomiting and GI bleeding and had a discharge diagnosis of Urinary Tract Infection, vomiting and gallstones. Two new medications were prescribed- LevoFLOXacin 750 mg (7 days) and Zofran 4mg (3x/day for 3 days). LPA reviewed medication counts for both medications and confirmed (R1) received both medications for (3) days, as prescribed, until passing. The caregiver stated there are delays at times with this health care company picking up medications and delivering it to the facility. The caregiver stated the California Hwy Patrol arrived just prior to emergency personnel arrived at 11:27 am on June 16, 2026. LPA requested a copy of the county death certificate when available , and the Administrator agreed to provide one. The facility will submit an amended copy of the death report (LIC624A) to reflect an accurate year and place of death. There are no deficiencies cited in this report. Exit interview with caregiver. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 26, 2026

Allegation investigated: Facility staff are obstructing fire exits to prevent residents from leaving. Facility staff are leaving residents alone at the care home without supervision. Facility is not providing adequate food services to residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings to a complaint received on May 19, 2026, and with met with Robert Kovacs, caregiver. LPA explained purpose of inspection. The administrator arrived at 12;35 pm. During the investigation, LPA interviewed the administrator, (1) staff and (3) current residents. LPA attempted to interview a family member of resident (R1), who is the subject of the investigation, but was not able to contact them. LPA reviewed documentation including (R1's) Physician Report, Pre-Appraisal, Admission Agreement, and other documenation. LPA took photographs of the hallway near (R1's) room and the food on hand at the facility. The results of the investigation are as follows: Resident (R1) moved to the facility on April 9, 2026, under a "respite" admittance for (2) weeks initially, but stayed until May 18, 2026. The physician reports notes (R1) has a diagnosis of Intertrochanteric fracture of right femur, history of falling, difficulty in walking, cognitive communication deficit and required asssitance with repositioning and transferring. (R1) also required a fortified diet, regular texture, thin consistency. *cont on 9099C-1.. Unfounded 9099C-1...The physician's report notes (R1) also needed assistance with bathing, dressing and toileting and can leave the facility with assistance. The Pre-Appraisal notes (R1) needed help with moving around the facility, toileting and needed special observation/night supervision due to confusion/forgetfulness. Allegation: Facility staff are obstructing fire exits to prevent residents from leaving. The allegation states staff are putting chairs under the door handles at night to prevent residents from leaving the facility. The Administrator and caregiver stated that a chair was placed outside of (R1's) room, with (R1's) permission to serve as a reminder for (R1) to call for assistance, when needed, to use the bathroom, or leave their room since it was near a ramp. Both staff stated this idea was approved by (R1's) Physical Therapist, due to (R1) having "mild Dementia- mostly memory issues". LPA viewed (R1's) room and chair that is kept outside the room in the hallway and took photos. LPA observed the top of the chair to be several inches below the door handle on (R1's) room and not be able to prevent the door from being opened. The chair was placed in front of the door, without touching it. Both staff denied that any other chairs were placed in front of any other doors. LPA did not observe any chairs nearby other doors in the facility. Both staff confirmed that the facility has "on-call" staff who will provide regular incontinent care and answer when residents need assistance.(R1) was unable to be interviewed due to moving from the facility on/around May 18, 2026. LPA was also not able to contact a family member of (R1) after attempting to. Based on interviews conducted and observations made, the allegation is found to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Facility staff are leaving residents alone at the care home without supervision. The allegation states it was understood that the care home had 24/7 supervision from caregivers; however, the care home does not have care staff at night. The lead care staff confirmed the Administrator and another staff, who lives at the care home, were filling in when he went on vacation for two weeks. The Administrator stated she was working daily at the facility, including providing nighttime care and supervision, when the lead staff was out of the facility. The lead staff was adamant that staff is present at all times and staff has contacted 9-1-1, on multiple occasions, during the night time shift. *cont on 9099C-2.. 9099C-2.. The Lead staff stated he could hear the chair squeak when (R1) got up and slid the chair to the side, and one time it was at 2:00 am. This staff stated he caught (R1) a couple of times" at the bottom of the ramp without using her wheelchair", and (R1) did not request assistance before ambulating down the ramp in their wheelchair. (R1) was unable to be interviewed due to moving from the facility on/around May 18, 2026. LPA was also not able to contact a family member of (R1) after attempting to. Based on interviews conducted and observations made, the allegation is found to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Facility is not providing adequate food services to residents. The allegation states that (R1) is receiving a bologna sandwich for every meal and nothing else. The lead staff stated bologna and other sandwiches are usually served at dinner, along with soups, salad and yogurt. and he offered (R1) bologna sandwiches and (R1) "never complained about it". Additionally, this staff offered (R1) eggs with spinach, but (R1) didn't like spinach or oatmeal, and confirmed (R1) was able to communicate. This staff added that (R1) would not eat any "green vegetables", even if blended in a smoothie. The Administrator stated she purchases a variety of foods on a regular basis and shops at various grocery stores. Additionally, while the lead staff was away, she and a second staff picked up soups and sandwiches from Panera Bakery. LPA observed the refrigerator and freezer to be full with fresh and frozen food on May 20, 2026, including meats and produce. LPA observed a fully stocked pantry also. The administrator commented that (R1's) family "took them out a lot- they just took them early in the morning at 7:00" without telling the facility staff, and they would eat out a lot. *cont on 9099C-3... 9099C-3.. Three (3) residents stated to LPA that the facility serves a variety of food, and bologna sandwiches are not served at every meal. All residents stated the food is "good" with one resident asserting, "sometimes it is exceptional" and the food was "still good" when the main staff was on vacation. (R1) was unable to be interviewed due to moving from the facility on/around May 18, 2026. LPA was also not able to contact a family member of (R1) after attempting to. Based on interviews conducted and observations made, the allegation is found to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview. Copy of report provided. 9099A-C-1... Allegation: Facility is not addressing resident's falls. The allegation states (R1) has several bruises due to falling and has sustained four (4) falls since residing at the care home. The complaint report does not reference the dates of the alleged (4) falls. The lead staff stated (R1) fell before moving in and broke their hip and stated (R1) "was at risk for falling and would come out of their room, without a walker, even at 2:00 am, more than once". This staff stated, "the Physical Therapist told (R1) not to walk without a walker", confirmed (R1) would use a wheelchair sometimes, and he told (R1), "it's dangerous" if they don't use the wheelchair all the time. The lead staff stated (R1) liked to use the guest bathroom near their room, but they needed to use the bathroom near the kitchen and explained, "If (R1) fell inside the guest bathroom, there is no way to open the door if they were blocking the door", confirming he and the administrator encouraged (R1) to use the larger bathroom with (2) doors, one on each end of the bathroom. This staff and the administrator stated (R1) never fell in the bathroom, but only slipped two times, from the wheelchair to the floor. When staff went to provide assistance, (R1) stated they "slipped", without any visible injuries or pain, and refused to be sent out. This staff provided (R1) with two pairs of hospital, non-skid socks and inspected (R1s) footwear. The lead staff stated the administrator "was upset that he caught (R1) a couple of times" at the bottom of the ramp without using their wheelchair. This staff stated the administrator told (R1) and their family she can't keep (R1) because they are "not listening". The lead staff stated the family asked for a second chance, and it was agreed to extend their respite stay. The Administrator stated she asked (R1) to call for assistance before going down the ramp in their wheelchair, but (R1) would forget and say they "promise not to again". The lead staff commented (R1) would use their wheelchair, hold the rail, and was good about calling for help during the day, but wasn't good about calling during the night. LPA took photos of the hallway area outside of the room where (R1) resided. LPA observed the hallway to have an incline when going to (R1's) room and a decline when leaving (R1's) room towards the common area. LPA observed hand rails on both sides. Both the Administrator and lead staff stated that (R1) was regularly out of the facility and would spend days, at a time, with their family. Both staff confirmed that (R1) would refuse showers at the facility as they take them with their family member, which the family member confirmed with staff. *cont on 9099A-C2.. 9099A-C-2... Additionally, the administrator and staff stated that (R1) went out with some friends who picked (R1) up in a large SUV vehicle, high off the ground, at least twice. The visitor sign-in log shows one of these visits occurred on May 8, 2026. Both staff stated (R1) returned one time with a small Band-Aid on one of their upper arms. Staff provided First Aid and (R1) didn't provide any details. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 5, 2026 · control 59-AS-20260519113825

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence a complaint investigation and with met with Robert Kovacs, caregiver, and explained purpose of inspection. Administrator, Eva Nemethy, arrived at 2:30 pm. LPA observed (3) residents in their rooms at the start of the inspection. There are no residents under hospice. LPA observed (1) resident return from health care provder/recreation and was advised (1) resident (R2) is still hospitliazed from March 28, 2026. LPA interviewed the Administrator, (1) staff, and a case manager from a health care provider. LPA reviewed documentation relating to resident (R1), including the Physician's Report, Admission Agreement, incident report, and appraisal/care plan. The results of the investigation are as follows: (R1) moved to the facility on February 14, 2026 post surgery to the abdominal midline and with an ileostomy that home health was caring for and Stage 4 Kidney failure. (R1) did not have any neurocognitive impairments. *cont on 9099C-1.. Substantiated 9099C-1 *this page was amended on May 20, 2026 to correct (2) grammatical errors* Allegation: Unlawful Eviction: The allegation states that resident (R1) was reportedly told they have (3) days to vacate while hospitalized. LPA spoke with a representative from a health care provider that stated the facility was "refusing to take (R1) back" for the reason that they "can't manage the ileostomy". The representative stated the facility administrator stated she would provide a 3-day notice to (R1), and then refused to take them back from the hospital. (R1) was placed at another board and care. Both the Administrator and staff stated that (R1) began declining each week shortly after moving in due to their diagnoses, including cancer and (R1) refusing to get chemotherapy treatment, dialysis, a hospice evaluation and going to the Emergency Room for (3) days. An incident report was submitted to the department along with a signed refusal from (R1), dated March 21, 2026. The Administrator stated that the hospital contacted her after (R1) had been in the hospital for (4-5) days and asked if (R1) could return to the facility. The administrator stated she was not comfortable taking (R1) back with the ileostomy because there were issues the nurses were aware of, a large wound near the ileostomy site, which was present when (R1) moved in but became stabilized after a few weeks due to the nurses oversight. Additionally, the skilled nursing stated to the facility that (R1) would be having another type of surgery (2) weeks after moving in and an ileostomy would not be needed after that, but the surgery did not happen due to (R1) not obtaining a physician. (R1) was sent out to the Emergency Room on March 22, 2026 due to finally agreeing to go after having no urine output for three days. The admission agreement states that (30) day written notice will be issued as a condition for eviction, and a (3) days may be given with provided there is written approval from the Department. The administrator confirmed that a written eviction notice was not issued to (R1) and (R1) did not return to the care home. Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights emailed.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 59-AS-20260330170806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.683(a)(1) · Plan of correction due date: Apr 16, 2026

§1569.683 Eviction notices; reasons for eviction contents; service. a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (1) The effective date of the eviction.This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure a 30-day eviction notice was issued to (R1), who was refusing emergency services, including there being issues with ileostomy bag, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: Licensee/Administrator agrees to consider respite care, if appropriate, and to admit residents on a short-term basis. Licensee/Administrator agrees to read Reg 87507/Admission Agreement and submit a statement of understanding. Due by April 16, 2026. LIcensee/Administrator agree to reach out to the Department LPA or Officer of the Day with questions.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct an annual continuation inspection from October 23, 2025. LPA met with Robert Kovacs, caregiver, and explained purpose of inspection. Administrator, Eva Nemethy, was contacted and arrived at 2:20 pm. Administrator Designee, Szabolcs Nemethy, arrived around 2:25 pm. LPA observed (6) residents to be in their rooms at the start of the inspection. There are no residents under hospice. During today's inspection, LPA reviewed staffing files and observed staff (S1) to have documentation of training completed November 2024. The administrator understands required yearly training must be completed every 12 months, or by end of November 2025. All staff have current First Aid and CPR documentation on file. LPA observed newly purchased plastic tubs with lids for medication. Administrator agrees to provide a copy of the Infection Control Plan as it was not able to be located during the inspection. Also, the administrator is in the process of requesting the updated Dementia care plan to add to the facility Plan of Operations. Discussed reporting requirements to the Department and types of incidences where a report (LIC624) need to be submitted. LPA requested a copy of the current liability insurance, Infection Control Plan and LIC308 be provided to LPA by email by 11/6/25. There are no deficiencies issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Robert Kovacs, caregiver, and explained purpose of inspection. Administrator, Eva Nemethy, was contacted and arrived at 1:30 pm. LPA observed (6) residents to be in their rooms at the start of the inspection. There are no residents under hospice. 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, slip-resistant 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 70*F. Hot water measured 116*F in the kitchen. Fire extinguisher is scheduled to be serviced by 12/3/24. LPA reviewed (2) of (6) resident files and found them to contain the required and current paperwork. LPA reviewed medications for (1) resident- orders match medications and documentation is being maintained. (2) residents were interviewed today. Staff files to be reviewed at annual continuation inspection. Administrator has RCFE Administrator certificate #7005454740- exp 7/20/2026. Discussed reporting requirements in detail and provided a copy of an LIC624. Also discussed updates to Regulation 87463/Reappraisals (copy provided) and Dementia care regulations. Administrator agrees to obtain updated regulations for the Plan of Operation. Discussed more organization with the medications that are being provided in bubble packs. LPA will return on another day this month to complete the annual. There are no deficiencies cited in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Robert Kovacs, caregiver, and explained purpose of inspection. Administrator, Eva Nemethy, was contacted and arrived at 3:00 pm. LPA observed (3) residents to be in their rooms at the start of the inspection and (1) resident return during the inspection. There are no residents under hospice. 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 73*F. Hot water measured 112*F in the kitchen. Fire extinguisher is scheduled to be serviced by 11/30/24 and has been pre-paid (last serviced 11/11/23). There is (1) unlocked gate from the inside back patio. There are no bodies of water or a pool. LPA reviewed (2) of (4) resident files and found them to contain the required paperwork. LPA reviewed medications for (1) resident- orders match medications and documentation is being maintained. LPA reviewed (2) staff files. Both staff have current First Aid and another staff has both First Aid/CPR. Administrator to complete CPR training so a second staff is certified. Documentation shows a main staff completed 25+ hours of required annual training in November 2024. Administrator RCFE Certificate is pending renewal. Administrator created a binder (red) for Emergency Disaster Plan and Infection Control Plan today for easy access. There were no citations issued; however, there are (2) Technical Violations issued. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 21, 2024