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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603519
Report Date: 03/27/2023
Date Signed: 03/27/2023 05:16:17 PM

Document Has Been Signed on 03/27/2023 05:16 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:KALI'S QUALITY HOME, INCFACILITY NUMBER:
198603519
ADMINISTRATOR:SABILLO, VENERANDAFACILITY TYPE:
735
ADDRESS:18226 ESPITO STTELEPHONE:
(951) 217-2318
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 0DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Rachell Sabillo TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Rachel Sabillo allowed the entry of the facility. The purpose for the visit was explained. The facility is licensed for Age Range 18 through 59 for Ambulatory only. Currently there's no client reside in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility is cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant and Environmental: Facility is a single story house and located in a residential neighborhood area. The home includes: living room, kitchen, dining area, activity area, staff bathroom, staff office, three clients bedrooms and two client bathrooms and the back and front yard are maintained well. The hot water was tested at 115.7 degrees which is within Tittle 22 regulation. The facility has two days perishable and seven days non perishable food supply. The carbon monoxide detectors and smoke detectors are interconnected and they are working probably. All the chemicals and sharp knives are locked and inaccessible to clients
Operational Requirement: Currently there's no client reside in the facility and the facility is followed the plan of operation with planning to have 4 ambulatory clients only.
Staffing: Current there's no staff working in the facility.
Personnel Record Training: Currently there's no staff working in the facility. All staff files will be located in the file cabinet in the staff office. Administrator (Rachel Sabillo) Certificate will be expired on 11/24/23. Administrator is fingerprint cleared and associated with the facility. And her health screening and TB test are updated in the personnel file.

(See LIC 809C for continuation)


SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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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: KALI'S QUALITY HOME, INC
FACILITY NUMBER: 198603519
VISIT DATE: 03/27/2023
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Client's Right and Information: Currently there's no client reside in the facility
Client's record-incident information: Currently there's no client reside in the facility. No file can review but all the client flies will be locked in the file cabinet in the staff office
Food Service: All the food are probably stored in the refrigerator and the refrigerator is maintained at a required temperature
Health Related Services: Currently there's no client reside in the facility and therefore no one is taking any medication and no medication is stored in the facility at the present time. The First aid kit has all the required items.
Incident Medical Services: Currently there's no client reside in the facility. It does not apply for the facility
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: This domain does not apply to the facility as facility is not using restraint or seclusion:

LPA interviewed 1 Staff and due to no client reside in the facility and unable to interview any client. No deficiencies were issued today. An exit interview was held. A copy of this report was given to the Administrator Rachel Sabillo
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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