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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600497
Report Date: 05/20/2025
Date Signed: 05/21/2025 09:06:24 AM

Document Has Been Signed on 05/21/2025 09:06 AM - 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: 6DATE:
05/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:12 PM
MET WITH:Kadri Egbeyemi - Administrator
Kimberly Egbeyemi - Co-Administrator		TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Kadri Egbeyemi, Administrator and Kimberly Egbeyemi, Co-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 utilized the full Care Compliance and Regulatory Enforcement (CARE) Tools and observed the following:

Infection Control: The facility has submitted the Infection Control Plan. Staff are adhering to infection control requirements.
Operational Requirements: The Infection Control Plan was submitted to CCL. Surety Bond is in effect with bond amount of $2000 and expires on 08/24/2024. Fire/Disaster Drill was last conducted on 03/07/2025.
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 six (6) clients living in the facility. 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 a couch and tv in the attached which is being used as resting area for staff as per the Co-Administrator. 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 are (3) fire extinguishers on the side table in the dining area but Administrator cannot provide proof of recent service date or purchase. 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*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/20/2025
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Staffing: A total of four (4) staff including the Administrator provide care and supervision to the clients. 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 all (4) staff members. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 03/03/2026.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone.
Food Service: There are sufficient food supplies of 2-day perishable but insufficient supply of 7-day non-perishable items.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.
Client Records-Incident Reports: LPA reviewed clients files which 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 has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiency cited on LIC 809D. Technical Violations and Technical Assistance issued. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Kadri Egbeyemi.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2025 09:06 AM - It Cannot Be Edited


Created By: Bennette Pena On 05/20/2025 at 03:37 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed a couch and tv in the attached which is being used as resting area for staff which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/27/2025
Plan of Correction
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Administrator agreed to remove the sofa bed/couch in the attached garage and send photos to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
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