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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602985
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:11:03 PM


Document Has Been Signed on 02/13/2024 04:11 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:KITTY'S HOUSE OF REFUGEFACILITY NUMBER:
198602985
ADMINISTRATOR:MAXIE, EBONYFACILITY TYPE:
735
ADDRESS:1639 EAST 85TH STTELEPHONE:
(323) 484-9832
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY:6CENSUS: 4DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Ronald Brown - ManagerTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Ronald Brown and Denice Reed, House Managers for the facility, and was granted entrance. Administrator Ejike Mbamalu was informed of the visit over the phone. There are four (4) ambulatory clients that reside in the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility had a completed infection control plan.


Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of six (6) ambulatory mentally disabled clients between the ages of 18-59. It consists of five (5) client bedrooms, a living room, dining room, a kitchen, two shared client bathrooms of which Restroom #1 (R1) had a hot water temperature reading measured at 105.2 Degrees F and Restroom #2 (R2) measured at 105.6 Degrees F, a front and back patio area, and washer and dryer machines that are kept in the backyard of the facility. Knives, chemicals, and cleaning supplies are kept locked in a locked room that is currently being used as storage.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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Document Has Been Signed on 02/13/2024 04:11 PM - It Cannot Be Edited

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: KITTY'S HOUSE OF REFUGE
FACILITY NUMBER: 198602985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 2 out of 4 clients, because one of the shared client bedrooms does not have a door secured in the frame, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that all doors and fixtures within the facility are in good repair. Administrator is to email LPA photographic proof of the client's door's repair by the POC due date.
Type B
Section Cited
CCR
80020(c)
Fire Clearance
(c) A licensee of an Adult Residential Facility or Group Home utilizing secured perimeters shall conduct fire and earthquake drills pursuant to Health and Safety Code section 1531.15(h).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 4 out of 4 clients, as there was no documented fire and earthquake drills on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that documented fire and earthquake drills are conducted once every 6 months at the facility. Administrator is to hold a fire and earthquake drill at the home and send LPA documentation of the drills by the POC due date.
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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 04:11 PM - It Cannot Be Edited

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: KITTY'S HOUSE OF REFUGE
FACILITY NUMBER: 198602985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

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 4 out of 4 clients, as there was no furnished outdoor shaded area provided for them, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that there is a furnished outdoor shaded area available for the clients. Administrator is to email photographic proof of furnished outdoor shaded area to LPA by the POC due date.
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 staff members, as none of the staff files were kept at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that staff recoreds are kept on the premises of the facility at all times. Administrator is to email LPA the staff files for the 3 staff who work at the facility by the POC due date.
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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 04:11 PM - It Cannot Be Edited

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: KITTY'S HOUSE OF REFUGE
FACILITY NUMBER: 198602985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 4 out of 4 clients, as there was not a sufficient 7-day supply of non-perishable foods, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that a 2-day supply of perishable and a 7 day supply of nonperishable foods are available for the clients at all times. Administrator is to show LPA proof of the updated sufficienct supply of food in the facility by the POC due date.
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above in 4 out of 4 clients, as there were no client files present within the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that client files are available for review at the facility at all times. Administrator is to email the client files for all 4 clients by the POC due date.
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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 02/13/2024 04:11 PM - It Cannot Be Edited

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: KITTY'S HOUSE OF REFUGE
FACILITY NUMBER: 198602985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 4 out of 4 clients, as there is no emergency and disaster plan posted within the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator is to ensure that an emergency and disaster plan is posted and kept within the facility at all times. Administrator is to send the posted emergency and disaster plan to the LPA by the 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.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


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: KITTY'S HOUSE OF REFUGE
FACILITY NUMBER: 198602985
VISIT DATE: 02/13/2024
NARRATIVE
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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Fire alarm system is operational. The facility has one (1) fully charged fire extinguishers that are kept in the first and second floors of the facility. Cleaning supplies and toxic substances are inaccessible to clients. There currently is not a furnished outdoor shaded area provided for the clients
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for ambulatory mentally disabled clients between the ages of 18 – 59.


· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of three (3) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Staff files were not available for review at the facility, LPA was informed that it is kept at a separate office.


Client Rights/Information:

· Medication Administration Records (MARs) were kept outside the facility at the client’s day program, and were gong to be brought back at 5 PM.

Client Records/Incident Reports:

· Client files were not available for review, LPA was informed that they are kept at a separate office.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: KITTY'S HOUSE OF REFUGE
FACILITY NUMBER: 198602985
VISIT DATE: 02/13/2024
NARRATIVE
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 Food Service:

· The kitchen was inspected and did not have a sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.


· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· MARs were not reviewed because LPA was informed that the MARs was currently at the client’s day program and needed to be brought back by one of the house managers Ronald Brown.


Incidental Medical and Dental:

· Staff and client records were not available for review during the annual inspection.

Disaster Preparedness, and Emergency Intervention:

· There was no emergency and disaster plan posted within the facility.

· There were no documented fire or earthquake drills on file at the facility.



Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.



Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided. Report will be emailed to the administrator as LPA has run out of printer paper.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7