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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606887
Report Date: 09/21/2022
Date Signed: 09/21/2022 10:50:35 AM


Document Has Been Signed on 09/21/2022 10:50 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:KATHLEEN CARE HOMEFACILITY NUMBER:
197606887
ADMINISTRATOR:ORLANDO J. VALERAFACILITY TYPE:
740
ADDRESS:1531 KIOWA CREST DRIVETELEPHONE:
(909) 860-8288
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 4DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Staff Victoria ValeraTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Victoria Valera and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
LPA Trueman toured the facility along with Administrator Orlando Valera today 9/21/2022 at 9:45 AM and the following was observed:
Facility contains 4 Client Bedrooms and 2 Client Bathrooms, 1 shower room for clients, dining room, living room, TV room, and laundry room.
Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables. Medication for clients were verified as being administered and a 30 day supply on hand.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Temperature checks are conducted 2x a day and logged.
Staff have been trained in hand washing. All staff have criminal clearance.
Staff are sufficient with no shortages and there is a plan to replace workers if ill.
There are rooms available if isolation is needed. Staff wear masks, gloves and face shields.
Bathrooms have proper signage for hand washing. There are multiple stations for hand sanitizing.
Social distancing is implemented. Meal times are sanitized after each meal.
Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. Advisory notices issued. No deficiencies.
Exit interview conducted.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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