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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600497
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:19:42 PM

Document Has Been Signed on 02/17/2023 01:19 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:KAO CARE SERVICESFACILITY NUMBER:
198600497
ADMINISTRATOR:EGBEYEMI, KADRIFACILITY TYPE:
735
ADDRESS:902 KIRKWOOD AVENUETELEPHONE:
(626) 529-5386
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
02/17/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kimberly EgbeyemiTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Kimberly Egbeyemi and discussed the purpose of today's visit.

This home consists of (3) bedrooms, (2) bathrooms, living room, dining room, kitchen and an attached garage. All clients residing at this home receive case management services provided by Frank D. Lanterman Regional Center.


The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supply stored inside the garage.
  • Hygiene supplies observed. Additional hygiene supply stored inside the garage.
  • Water supply observed. Additional water supply stored inside the garage.
  • Bathrooms have hand soap and paper towels. Bathrooms have hand washing signs posted.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Staff responsible for direct care and supervision was wearing their mask.
  • Clients will socially distance according to local public health guidelines.

LPA was experiencing technical difficulties during this visit. Exit interview conducted, a copy of this report and Appeal Rights were provided to Kimberly Egbeyemi
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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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