306004126-2-7-2025-22-AS-EKIM-DDP36H-20250207165821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004126
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:58:28 PM

Document Has Been Signed on 02/07/2025 04:58 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 HILLS		FACILITY NUMBER:	306004126
ADMINISTRATOR/ DIRECTOR:	REGAT Y. KEBEDE		FACILITY TYPE:	740
ADDRESS:	212 BLUEROCK STREET		TELEPHONE:	(714) 921-9346
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92807
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	02/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Assistant Administrator- Yonathan Kebede		TIME 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	On February 7, 2025, at 12:30pm, 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 was greeted and granted entry by Caregiver (CG) Ellein Bobis. Assistant Administrator Yonathan Kebede arrived at the facility as the Designated Facility Representative and LPA Kim explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents and has a hospice waiver for five (5) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with CG Bobis. There were no bodies of water or obstructions in the facility. 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 Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 106.3 degrees F to 109.9 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility. LPA Kim observed the facility to be 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 both were available and maintained properly. Evaluation Report Continues on LIC 809-C

Lourdes Montoya	TELEPHONE: (916) 956-7332
Edward Kim	TELEPHONE: (714) 293-1237
	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

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 2

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
	VISIT DATE: 02/07/2025

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
26
27
28
29
30
31
32

During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A working telephone (714-921-9346) remain available. Last emergency drill was conducted on January 28, 2025, and is conducted quarterly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted in the kitchen. LPA Kim conducted an audit of staff files (S1-S6). LPA Kim conducted two (2) resident interviews.

The following observations were made and these deficiencies will be addressed on a subsequent visit: 1) there is a staff room inside the family room that is not reflected in the facility sketch and 2) there are three walls bolted on the ground with 14.75” space from the ceiling that is not reflected in the facility sketch.

Due to time constraints LPA will conduct the following on a subsequent visit: LPA will conduct record review for residents, an audit of medication and medication administration review, conduct staff interviews, check the smoke detectors and carbon monoxide detectors, review the internet device with video teleconferencing dedicated to the residents, and review the first aid kit on the next visit.

No deficiencies were cited during today’s visit.

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

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2