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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004126
Report Date: 02/21/2025
Date Signed: 02/21/2025 11:53:18 AM

Document Has Been Signed on 02/21/2025 11:53 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:K'S LOVING CARE IN ANAHEIM HILLSFACILITY NUMBER:
306004126
ADMINISTRATOR/
DIRECTOR:		REGAT Y. KEBEDEFACILITY TYPE:
740
ADDRESS:212 BLUEROCK STREETTELEPHONE:
(714) 921-9346
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator- Regat Kebede
Assistant Administrator- Eyob Kebede		TIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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On February 21, 2025, at 9:20 am, Licensing Program Analyst (LPA) Edward Kim conducted a continuation visit for a required 1-year annual visit. LPA Kim was greeted and gained entry by Caregiver (CG) Ellein Bobis. Assistant Administrator (AA) Eyob Kebede and Administrator (AD) Regat Kebede arrived to the facility.

LPA Kim conducted an audit of resident records (R1-R4) and medication and medication administration record that were complete and in order. LPA Kim conducted staff interviews (S1-S2). First aid kit is maintained and contains all the necessary elements. The smoke detectors and carbon monoxide detectors were operable. A video teleconferencing device is dedicated to the residents remain available.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. LPA observed the following deficiencies: there is a staff room inside the family room that is not reflected in the facility sketch and there are three walls bolted on the ground with 14.75” space from the ceiling that is not reflected in the facility sketch.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Assistant Administrator Eyob Kebede and Regat Kebede.

Lourdes MontoyaTELEPHONE: (916) 956-7332
Edward KimTELEPHONE: (714) 293-1237
DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 02/21/2025 11:53 AM - It Cannot Be Edited


Created By: Edward Kim On 02/21/2025 at 11:12 AM
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
, 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: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above. LPA observed three walls bolted to the floor with 14.75" space from the ceiling that is not reflected in the facility sketch. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Licensee states they will go and obtain building permit from Anaheim Building Department to build a staff bedroom. They will send proof to CCLD via email to Edward.Kim@dss.ca.gov by POC due date March 7, 2025.
Type B
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above. LPA observed a staff bedroom with two beds in the family room that is not in the facility sketch. This poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Licensee cleared the beds from the staff room on February 21, 2025. The deficiency is cleared on February 21, 2025.
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:Lourdes Montoya
TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME:Edward Kim
TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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