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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606887
Report Date: 08/30/2024
Date Signed: 08/30/2024 12:59:50 PM


Document Has Been Signed on 08/30/2024 12:59 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:
08/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Orlando Valera, LicenseeTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA arrived unannounced and met with licensee, Orlando Valera. The initial inspection began on 8/27/24.

During the visit today, LPA inspected the remainder of the domains.
Staffing: The administrator's (Orlando Valera) certificate expired on 8/21/24. The administrator had submitted the renewal via mail and is pending approval. Staff employed are over the age of 18 and are fingerprint cleared.
Personnel Records-Training: LPA reviewed the Administrator and 2 other staff files. There are sufficient annual training on file. CPR & First Aid certificates are current for all 3 staff.
Resident Records-Incident Reports: LPA reviewed 6 resident files and they have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Resident appraisal, and Resident rights.
Resident Rights-Information: The Local Ombudsman and Residents personal rights information are posted at the facility.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability.
Incidental Medical & Dental: The medications are centrally stored in their original containers. LPA reviewed 6 residents' medications and no discrepancies were found.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and procedures. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. There are currently 2 residents in hospice.

No deficiencies issued today. An exit interview was held and 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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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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