306001456-7-30-2024-22-AS-EKIM-D7NRGJ-20240730130049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001456
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:01:49 PM

Document Has Been Signed on 07/30/2024 01:01 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	K'S LOVING CARE IN YORBA LINDA		FACILITY NUMBER:	306001456
ADMINISTRATOR:	KEBEDE REGAT		FACILITY TYPE:	740
ADDRESS:	19192 MC CARTHY LANE		TELEPHONE:	(714) 693-9156
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 2	DATE:	07/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Regat Kebede		TIME COMPLETED:	01:15 PM

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On July 30, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Regat Kebede and explained the purpose of the visit.

The facility is licensed to operate for six (6) nonambulatory and have a hospice waiver for three (3). The facility is a single-story structure in residential neighborhood, which consists of the following: five (5) bedrooms (of which 4 bedrooms are for residents and 1 for staff), two (2) bathrooms, living area, dining area, kitchen, outdoor shaded patio area, and an attached garage.

LPA Kim toured indoor and outdoor of the physical plant with AD Kebede. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.9 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. A working telephone (714-693-9156) remains available. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducts fire/safety drills quarterly. The facility has two (2) fire extinguishers that are charged and they were all serviced on February 9, 2024, smoke detectors, and carbon monoxide detectors were operable.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: K'S LOVING CARE IN YORBA LINDA	FACILITY NUMBER: 306001456
	VISIT DATE: 07/30/2024

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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Emergency food, emergency water and emergency supplies were stored in the garage. First Aid was maintained.

LPA Kim conducted an audit of two (2) resident files (R1-R2), three (3) staff files (S1-S3), and medication and medication administration record were all in order and complete. LPA conducted two (2) staff interviews.

A Technical violation was assessed during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of this report was provided to Administrator Regat Kebede.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

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