<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603519
Report Date: 01/23/2025
Date Signed: 01/23/2025 06:43:44 PM

Document Has Been Signed on 01/23/2025 06:43 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/
DIRECTOR:		SABILLO, VENERANDAFACILITY TYPE:
735
ADDRESS:18226 ESPITO STTELEPHONE:
(951) 217-2318
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 2DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Rachel Sabillo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 1/23/25. LPA met with Staff, Roselyn Ochoada, and explained the reason for the visit. The facility is approved for 4 ambulatory only clients, ages 18 - 59. There are currently 2 clients residing at the facility.

LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools.
The single story facility is located in the residential area. It consists of 3 client bedrooms, 2 client bathrooms, 1 staff bathroom, living room, family room, staff office, and kitchen. Client bedrooms have the required furnishing and lighting. Bathrooms are kept clean. There are smoke and carbon monoxide combo detectors located throughout the house and are interconnected. Knives and cleaning supplies are locked. Sufficient food supplies of perishable and nonperishable are observed. Staff are continuing to follow their Infection Control Plan. The water temperature was measured over 130 degrees for both client bathrooms, which is over the required range of 105-120 degrees F.
LPA observed surveillance cameras in the common areas of the facility and informed the administrator to update their plan of operation, admission agreement, and facility sketch to send to LPA.
LPA reviewed both client files and they have the required documents on file. Medications are centrally stored and reviewed for both clients. There were no discrepancies found. LPA reviewed 3 personnel files. The administrator's (Rachel Sabillo) certificate expires on 11/24/25. Staff files are complete and are receiving on-going training.
The Emergency and Disaster Plan is current and reviewed annually by the administrator. A technical violation is issued for the emergency drills as the facility has not been conducting them at least quarterly.

A deficiency is given today along with a civil penalty due to it being a repeat violation. An exit interview was held and a copy of this report, LIC809D, appeal rights were given to Administrator Sabillo.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/23/2025 06:43 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 01/23/2025 at 04:37 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: KALI'S QUALITY HOME, INC
FACILITY NUMBER: 198603519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in which the hot water temperature in the bathrooms were measure over 130 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
1
2
3
4
Administrator will adjust the hot water temperature and measure the water daily for a week to ensure it falls between the range of 105-120 degrees. Administrator will submit a statement certifying that the hot water will stay within range by POC due date and the temperature log after 7 days.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3