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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606887
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:45:59 PM


Document Has Been Signed on 09/26/2023 03:45 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:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Orlando Valera, licenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with licensee, Orlando Valera. The purpose for the visit was explained. The facility is licensed to serve 6 non-ambulatory elderly residents. The hospice waiver is approved for 2 residents.

LPA toured and inspected/observed the facility using the Compliance and Regulatory Enforcement (CARE) tools:
The facility does not have any bodies of water or pool on site. There are 4 resident bedrooms, 1 staff room, 1 office, 2 bathrooms, living room, dining room, kitchen, and attached garage. Facility has operable smoke detectors and a carbon monoxide detector located in the dining area. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility. The facility has a fire place but is covered. Staff are using appropriate hand hygiene and gloves while assisting residents during showers and changing diapers. The facility has submitted an Infection Control Plan. The facility accepts and retains residents with dementia. There are currently 6 residents residing at the facility. The facility has the sufficient amount for liability insurance. Administrator (Orlando Valera) certificate expires on 8/21/24. Staff employed are fingerprint cleared and associated to the facility. LPA reviewed the Administrator and 2 other staff files. LPA observed current CPR and First Aid certificates for all 3 personnel. LPA reviewed 6 resident files. Each file has the admission agreement, Physician's Report, Reappraisals, Consent forms, and Personal Rights form. There are appropriate agencies postings on the walls. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient food supplies of 2-day perishable and a week of non- perishable items. The foods are properly stored in the refrigerator. Medications are centrally stored and in their original containers. There were no discrepancies for all 6 residents' medications reviewed and facility is following physician's orders. The facility has an Emergency Disaster Plan posted with contact numbers.

LPA provided a technical assistance on emergency disaster drills. 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: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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