019200723-3-27-2024-15-AS-CFOR-D3RTTB-20240327150028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:00:38 PM

Document Has Been Signed on 03/27/2024 03:00 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	KIMBILIO		FACILITY NUMBER:	019200723
ADMINISTRATOR:	ALANNA SPENCER		FACILITY TYPE:	772
ADDRESS:	1480 159TH STREET		TELEPHONE:	(510) 200-9134
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY: 14		CENSUS: 8	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	JONATHAN HASKINS, FACILITY CASE MANAGER		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 3/27/2024 at 9:50AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual required inspection and met with Jonathan Haskins, Facility Case Manager. Administrator, Ibrahim Kamara arrived at 11:00AM. This is a Social Rehabilitation Facility with the capacity of 14. Currently there are 8 clients living at the facility. Clients stay for 6 months or less. On a situation basis, clients may request for extension of stay.

LPA inspected the facility inside and out including but not limited to common areas, computer room, client rooms, bathrooms, kitchen, laundry room and storage. Facility in compliance with State Fire Marshall Regulations. Facility is clean and in good repair. Smoke detector and carbon monoxide detector are in working condition. First aid kit is complied with regulation. Outside area is free of obstruction and bodies of waters. Fire extinguisher is full and was last serviced on 8/9/2023. Emergency plan posted. Water temperature reads 120 degrees Fahrenheit. Medications are centrally stored in a locked area that is inaccessible to clients. Toxins are locked and separated from stored foods. Knives stored in kitchen pantry and locked. There are 2-day perishable and 7-day non-perishable food supply on hand. There are sufficient linen and hygiene supplies stored.

LPA reviewed 5 of 8 client files and 4 of 10 staff files. All are current and updated. .

On 3/27/2024, the following deficiencies were found:

At 10:21 AM, LPA observed chemicals unlocked in the kitchen cabinet.

At 10:22 AM, LPA observed knives unlocked in a kitchen cabinet.

Continue on LIC 809-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KIMBILIO	FACILITY NUMBER: 019200723
	VISIT DATE: 03/27/2024

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CONTINUE FROM LIC 809

LPA requested the following documents to be updated and submit to Community Care Licensing by 04/05/2024:

1. LIC 309- Administrative Organization

2. LIC 308- Designation of Facility Responsibility
3. LIC 500- Personnel Report
4. Certificate of Liability Insurance
5. LIC 610D- Emergency Disaster Plan

Type A/B deficiencies are cited per California Code of Regulations, Title 22, and listed on LIC 809-D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.

Exit interview conducted appeal rights provided and copy of report given.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 03:00 PM - It Cannot Be Edited

Created By: Carol Fowler On 03/27/2024 at 01:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KIMBILIO	FACILITY NUMBER: 019200723
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81087(a)(I)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions, and poisons are stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above having disinfectants, cleaning solutions and sharps located in an unlocked cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/28/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all disinfectants, cleaning solutions and sharps locked at all times. Administrator locked cabinets. DEFICIENCY CLEARED DURING VISIT.

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:

Bennett Fong

LICENSING EVALUATOR NAME:

Carol Fowler

LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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