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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603519
Report Date: 01/24/2022
Date Signed: 01/24/2022 10:38:40 AM

Document Has Been Signed on 01/24/2022 10:38 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KALI'S QUALITY HOME, INCFACILITY NUMBER:
198603519
ADMINISTRATOR:SABILLO, RACHELFACILITY TYPE:
735
ADDRESS:18226 ESPITO STTELEPHONE:
(951) 217-2318
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 0DATE:
01/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rachel Sabillo (Licensee/Administrator)TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kruz Long conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. Upon arrival, LPA met with Rachel Sabillo who assisted with the inspection.

An application was received on 08/20/21 for Initial License #198603519, Adult Resident Facility to serve ages range 18 to 59.

The facility is a single story house located in a residential area which consist of a living room, kitchen, dining area, 3 client bedrooms, 1 activity room, 3 bathroom, 1 office and 1 attached garage/storage/laundry. The client bedrooms are spacious and easily accommodate the client's furnishings. There is a back yard with a covered gazebo. Passageways, walkways, driveway, step and patios are free of obstructions. Front, back and side areas are free of hazards. Bedrooms has beds, chairs, night stands, shared lamps in addition to overhead lighting. There are dressers, drawers, which comply with the requirement of 8 cubic feet of space. Bathrooms have a working toilet, wash basin, bathtub/shower. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. There are adequate supply of linens. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review in the activity room. Fire Extinguisher located in the activity room mounted to the wall. Telephone system is a land line located in the living room and kitchen. Dishes, cups and flat ware are stored in the kitchen, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked in the kitchen drawer. Food supply adequately stored in kitchen cabinets and refrigerator. Smoke Detectors and Carbon monoxide detector are operational. Stove burners, oven, microwave, washer, and dryer working. There is one refrigerator in the kitchen. Toxins are locked and stored. Hot water temperature measured within Title 22 guidelines in the bathroom. A first aid kit has been inspected and consist the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen cabinet available for staff use but inaccessible to clients. Continue to LIC809C......
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KALI'S QUALITY HOME, INC
FACILITY NUMBER: 198603519
VISIT DATE: 01/24/2022
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Applicant will be handling cash resources of clients. Cash resources will be locked and stored with P & I Ledger in the office, accessible to designated staff. Personnel and Client records will be stored in a locked cabinet in the office. The facility has board games, books, and other recreational materials for the client's use located in the living room. Client medications will be centrally stored and locked in the kitchen cabinet. There are no Pool/Jacuzzi & Pets on the premises. Fire Clearance was granted on 10/08/21.

Component III: Waved: Licensee is currently operating under License #198602383 of the same category.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC809 (FAS) - (06/04)
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