<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600497
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:20:25 PM

Document Has Been Signed on 04/11/2024 04:20 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/
DIRECTOR:		EGBEYEMI, KADRIFACILITY TYPE:
735
ADDRESS:902 KIRKWOOD AVENUETELEPHONE:
(626) 529-5386
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 6CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Kadri Egbeyemi - Administrator
Kimberly Egbeyemi - Assistant Administrator		TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Kadri Egbeyemi, Administrator and Kimberly Egbeyemi, Asisstant Administrator and explained the purpose of the visit. The facility is licensed to care for six (6) Developmentally Disabled Adults, ages 18 through 59, ambulatory only.
All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center. LPA observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located near the front door.The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan was submitted to CCL and will be added to the Plan of Operation. Surety Bond is in effect with bond amount of $2000 and expires on 08/24/2024. Fire/Disaster Drill was last conducted on 12/07/2023.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains three (3) client bedrooms, two (2) full bathrooms, living room, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. Facility is a Level 2. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, night stand, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and LPA observed (2) large dogs outside. LPA did not observe outside furniture in the backyard but shaded area is provided in the front yard. Attached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. LPA observed that there is a couch and tv in the garage and the Asst. Administrator stated that the area is being used as resting area for staff. Kitchen knives, sharps objects, are kept locked in a locked cabinet in the kitchen/dining area. The cleaning supplies and toxic substances are stored in a cabinet under the sink which is also kept locked and inaccessible to clients. There is one (1) fire extinguisher which was just purchased during the visit (04/11/2024). Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings were within the required 105-120 degrees Fahrenheit. *****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SERVICES
FACILITY NUMBER: 198600497
VISIT DATE: 04/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staffing: A total of four (4) staff including the Administrator provide care and supervision to the clients. One of the staff showed as live in staff on LIC500/Staff roster. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 04/12/2024.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Three (3) clients have their own personal cell phone and no clients have tablets/IPads.
Food Service: There are sufficient food supplies of 2-day perishable but insufficient supply of 7-day non-perishable items. Additional food supplies were purchased during the visit. The food is properly stored in the refrigerator. There are zero (0) client with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services The medications are centrally stored and in their original containers. Medications were reviewed for C1-C3 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.
Incidental Medical Services: Per the Administrator, there is no client at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility does have a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Kadri Egbeyemi.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/11/2024 04:20 PM - It Cannot Be Edited


Created By: Bennette Pena On 04/11/2024 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KAO CARE SERVICES
FACILITY NUMBER: 198600497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the Administrator did not comply with the section cited above in that Fire Drill was not conducted on a quarterly basis as required. The last fire drill was last conducted on 12/07/2023 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 04/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct the fire/disaster drill with staff and submit the in-service training signed/dated by all facility staff to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4