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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004126
Report Date: 02/06/2024
Date Signed: 02/06/2024 02:10:25 PM


Document Has Been Signed on 02/06/2024 02:10 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 ANAHEIM HILLSFACILITY NUMBER:
306004126
ADMINISTRATOR:REGAT Y. KEBEDEFACILITY TYPE:
740
ADDRESS:212 BLUEROCK STREETTELEPHONE:
(714) 921-9346
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 5DATE:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Keede RegatTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Regat Kebede and explained the reason for the visit. The Administrator's certificate expires on 3/15/2024. LPA and Administrator toured the facility. Facility is a 5 bedroom home with 3 bathrooms, kitchen, living room with a room divider, dining room and a two car garage. LPA observed the fireplace in the living is room is screened. LPA observed the PUB 475 poster does not measure 20 X 26 inches, it is 12 X 16 inches. LPA observed a two day perishable and seven day non-perishable food supply in the kitchen. LPA observed the stove lights unassisted. The fire extinguisher in the kitchen is fully charged. The garage is kept locked and used for storage. LPA observed the cleaning supplies are kept locked in the garage. LPA observed all resident rooms were clean and had the required furnishings. The hot water measured 105.0 degrees Fahrenheit in all 3 bathrooms. All 3 bathrooms are clean and operational. LPA observed clean linens in the hall closet. The backyard has a covered patio with a seating area for residents. No bodies of water observed in the backyard. The exit gate is operational and is latched. No obstacles or hazards observed in the backyard. No obstacles or hazards observed in the facility. LPA inspected the first aid kit. The first aid kit does not have a current first aid manual but has all the other required elements. LPA reviewed 2 out of 2 staff files. Both staff have current CPR/First Aid training. Both staff only have 3 hours of current training. LPA reviewed 5 out of 5 resident files. LPA observed R1 did not have a signed physician's report (LIC 602A) and R3 who has been diagnosed with Dementia did not have a current physician's report. LPA observed all medications are kept locked in the hall closet. LPA reviewed 5 out of 5 resident medications. No discrepancies observed. LPA interviewed 2 staff. Residents declined to be interviewed. LPA consulted with Administrator concerning reporting requirements and facility record requirements. Violations are being cited per Title 22 division 6 of the California Code of regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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Document Has Been Signed on 02/06/2024 02:10 PM - It Cannot Be Edited

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 ANAHEIM HILLS
FACILITY NUMBER: 306004126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review, 2 out of 2 staff files reviewed did not have current resident rights training. Both staff files reviewed only had 3 hours of training which did not include resident rights training. The licensee did not comply with the section cited above in 2 out of 2 staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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LIcensee agrees to provide proof of staff training (17 hours) by the 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/06/2024 02:10 PM - It Cannot Be Edited

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 ANAHEIM HILLS
FACILITY NUMBER: 306004126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Each resident with Dementia shall have an annual medical assessment as specified in section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by: LPA reviewed R3's physician report (LIC 602A) and the exam was done on 1/6/2023 which is more than a year ago.
Deficient Practice Statement
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Based on a record review the licensee did not comply with the section cited above in 1 out of 5 physician's reports which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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Licensee agrees to have obtain an updated physician's report (LIC 602A) for R3 by the 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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