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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606887
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:07:39 PM


Document Has Been Signed on 08/27/2024 04:07 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
GREATER LA AC/SC, 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: 6DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Orlando Valera, LicenseeTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Cynthia Chan conducted an annual inspection using the Compliance and Regulatory Enforcement (CARE) tool. LPA arrived unannounced and met with licensee, Orlando Valera. The purpose of the visit was explained. The facility is approved for (6) non-ambulatory elderly residents. There is a hospice waiver approved for 2 residents.

LPAs toured the facility and inspected the following domains:
Infection Control: The facility staff are performing hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting daily. Facility continues to follow the infection control plan.
Physical Plant & Environment Safety: The facility consists of 4 resident, 2 staff rooms, 2 bathrooms, living room, dining room, kitchen, and attached garage. Extra linens are observed. Facility has an operable smoke detector in each room and a carbon monoxide detector. Knives and cleaning solutions are locked and inaccessible to residents. There are no swimming pool or bodies of water on the premises.
Operational Requirements: There are currently (6) residents residing at the facility and (2) are on hospice. The facility has the adequate amount for liability insurance.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. There is an extra refrigerator in the garage. Foods are properly stored in the refrigerators.

LPA will return another day to complete the remainder of the domains. There are no deficiencies issued today. A copy of this report was given to the licensee.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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