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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600497
Report Date: 03/09/2022
Date Signed: 03/09/2022 05:05:04 PM

Document Has Been Signed on 03/09/2022 05:05 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KAO CARE SERVICESFACILITY NUMBER:
198600497
ADMINISTRATOR:EGBEYEMI, KADRIFACILITY TYPE:
735
ADDRESS:902 KIRKWOOD AVENUETELEPHONE:
(626) 529-5386
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 5DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Kimberly Egbeyemi, Acting AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA met with the Administrator, Kimberly Egbeyemi and explained the purpose of the visit. The facility is licensed to serve six (6) developmentally disabled adults 18 to 59 years of age and are ambulatory only. There are currently 5 clients (placement by Frank D. Lanterman Regional Center) residing at the home.

LPA toured the facility and observed the following:
* The single-story home consists of 3 Client bedrooms, 2 bathrooms, living room, dining room, kitchen, and the garage. There are no pools or bodies of water at the facility.
* Upon entry, there is a station set up with masks, hand sanitizers, gloves, and sign-in log with temperature check.
* Signage are posted throughout the facility and in the bathrooms to promote proper cough/sneeze etiquette and hand washing. There are signs for social distancing in the seating areas.
* PPE supplies for at least 30 days are observed.
* Disinfectants and cleaning supplies are stored and locked in the garage.
* There are sufficient perishable and non-perishable food supplies.
* Knives and medications are stored and locked in the file cabinets located in the kitchen. LPA reviewed medications for 4 clients and are being administered as prescribed.
* The hot water temperature was measured between the required range of 105-120 degrees Fahrenheit.
* The smoke and carbon monoxide combo detectors are found in each of the bedrooms and one in the hallway. The facility also has a hard-wired fire alarms connected to the local fire department.
* No staff or client files were reviewed for this inspection.

No deficiency was observed during the visit today.
An exit interview was conducted and a copy of this report along with appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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