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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 06/27/2024
Date Signed: 06/27/2024 06:23:41 PM

Document Has Been Signed on 06/27/2024 06:23 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:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR/
DIRECTOR:		ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 14CENSUS: 5DATE:
06/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Kimberly Whitaker, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
06:40 PM
NARRATIVE
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On 6/27/2024 at 5:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Program Director, Kimberly Whitaker and explained the purpose for the visit.

While LPA G. Luk was at the facility for another visit the following deficiency was observed.

After reviewing Guardian system, LPA G. Luk observed staff (S1) did not have criminal record exemption transfer to this facility. S1 left the facility during visit and will return once exemption transfer is approved.

Civil penalty of $500 is being assessed.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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Document Has Been Signed on 06/27/2024 06:23 PM - It Cannot Be Edited


Created By: Grace Luk On 06/27/2024 at 06:02 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: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2024
Section Cited
CCR
81019(e)(3)

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Criminal Record Clearance. Request and be approved for a transfer of a criminal record exemption... This requirement is not met as evidence by:
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Facility has agreed to obtain criminal record exemption transfer for S1 and submit proof of communication to Guardian to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having criminal record exemption transfer for staff which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assessed.

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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