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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001456
Report Date: 03/07/2022
Date Signed: 03/08/2022 09:39:42 AM


Document Has Been Signed on 03/08/2022 09:39 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:K'S LOVING CARE IN YORBA LINDAFACILITY NUMBER:
306001456
ADMINISTRATOR:KEBEDE REGATFACILITY TYPE:
740
ADDRESS:19192 MC CARTHY LANETELEPHONE:
(714) 693-9156
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 3DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Kebede Regat, AdministratorTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Kathrina Chin made an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Regat Kebede and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory and with hospice waiver for three. For this visit, there was one resident under hospice care.

About 11:00 AM, LPA Chin was granted entry after completing the COVID 19 screening procedure. For this visit, there were three residents in care and three staff members on the floor. LPA toured the interior and exterior portions of the facility. There were five private resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 106 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had garden furniture in good repair, and grounds were free of tripping hazards. Side exit door was self-latching and self-closing. LPA Chin reviewed the COVID 19 mitigation plan of the facility.

LPA provided facility the general email address of the office: CCLASCPOrangeCountyRO@dss.ca.gov The facility will use the email address to send all incident reports and other general correspondence for Orange County Community Care Licensing Division Regional Office.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Regat Kebede and copy of this report was left in the facility
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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