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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603519
Report Date: 02/27/2024
Date Signed: 02/27/2024 10:55:01 AM

Document Has Been Signed on 02/27/2024 10:55 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: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:
02/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rachel Sabillo TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Christine Wong conducted the unannounced Annual Inspection and met with Administrator Rachel Sabillo who allowed the entry of the facility and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed for age range 18 through 59 and ambulatory only. The facility is vendorized as Level 4I home with San Gabriel Pomona Regional Center.

The following domains were reviewed during today's annual required visit which included: infection control, physical plant and environmental, operational requirements, staffing, personnel records-training, client rights- information, client records-incident reports, food service, health related services, incidental medical services, disaster preparedness and emergency intervention.

1. Infection Control: The facility staff would practice hand washing and using gloves when they have clients in the facility. Staff would clean and disinfect once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies and has an Infection Control Plan in place

2. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, three clients bedrooms and two clients bathrooms and patio/activity room, office and a detached garage. Bedroom#1 has two beds, two chairs, night stand, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one drawer, one night stand, required bedding and furniture and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature was tested over 130 degrees F which is not within the Tittle 22 regulation. All the appliance in the living room and kitchen are working well. The hallway light is always on so client can go to the non-private bathroom at night. The extra personal hygiene products will be store in client's drawers. The extra linen and towels are stored in the hallway cabinet. The passageway and walkway are free of obstruction. LPA inspected the carbon monoxide detectors and they are all working well.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 02/27/2024
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3. Operational Requirement: Currently facility has no client in the facility but facility is planning to admit client with the fire inspection requirement. Facility would also support client to participate the community activities if there's an opportunity or a chance. There's a table and chair with shaded area in the backyard for client to utilize the outdoor activity.

4. Staffing: Currently there's no client in the facility and therefore, there's no staff in the facility yet.

5. Personnel Records-Training: Due to facility currently has no client, there's no staff file to review but the facility administrator is Rachel Sabillo and her administrator certificate was expired on 11/24/23, currently the administrator certificate is pending with CCL system. The administrator has an updated HIV and TB training.

6. Client's Right: Currently the facility is a vacant, the domain is not applied to the facility.

7. Food Service: The facility has ample supply of 2 days perishable and 7 days non-perishable food supply in the facility, All the food are stored properly in the facility.

8. Client Record-Incident Reports: Currently the facility is vacant, therefore there's no client files to be reviewed.

9. Health Related Services: Currently the facility is vacant, therefore there's no client's medication to be reviewed.

10. Incident Medical Services: Currently the facility is a vacant, the domain is not applied to the facility.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan and the facility has two temporary shelter location. The facility is planning to conduct fire / disaster drill every 6 months.

12.Emergency Intervention: The facility is not planning on using any restraints on clients.

Due to the facility is vacant and no client to be interviewed

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit Interview Conducted and a copy of this report and appeal right was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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Document Has Been Signed on 02/27/2024 10:55 AM - It Cannot Be Edited


Created By: Christine Wong On 02/27/2024 at 10:36 AM
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: KALI'S QUALITY HOME, INC
FACILITY NUMBER: 198603519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA tested the hot water temperautre in both client's bathrooms and they were tested over 130 degrees F.
POC Due Date: 03/05/2024
Plan of Correction
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The administrator will lower the hot water temperature immediately and send the hot water temperature log to LPA in the next 7 days to 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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