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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006141
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:19:04 PM

Document Has Been Signed on 06/16/2022 02:19 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:KMA RESIDENTIAL CAREFACILITY NUMBER:
306006141
ADMINISTRATOR:JABONERO, NEILFACILITY TYPE:
735
ADDRESS:1467 W ASH AVE.TELEPHONE:
(714) 905-4603
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 0DATE:
06/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Anamika Ahluwalia & Anish GoreTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez made a visit to the facility to conduct an announced Pre-Licensing evaluation with a Component III. Upon arrival, LPA met with Applicant Anamika Ahluwalia and Direct Staff Anish Gore. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) for a Capacity of 4 (all Ambulatory) clients. The Fullerton Fire Department conducted a Fire Safety Inspection on 03/03/2022 and Fire Clearance was granted. A tour of the physical plant was conducted inside and out at approximately 01:00 PM with Applicant and Staff and the following was observed:
Structure:
Facility is a one story house with 4 bedrooms and 2 bathrooms. Bedrooms will be single occupancy. Facility will have no live-in staff. There is a kitchen, dining area, and living room.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Clients:
The client bedrooms accommodate clients' furnishings and meet Title 22 regulation at this time.
Bathrooms:
The 2 bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies
Adequate supply of linens and hygiene items were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Personal Rights and the See Something Say Something are posted. Ombudsman poster will be requested after licensure.
Food Service:
Facility has no clients during this visit. Applicant understands a supply of 7-day non-perishable and 2 day perishables and fruits and vegetables must be available when clients present at all times.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KMA RESIDENTIAL CARE
FACILITY NUMBER: 306006141
VISIT DATE: 06/16/2022
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems is centrally wired and operational.
Fire Extinguishers:
The Fire Extinguisher was mounted and fully charged.
Appliances:
Refrigerator/freezer, microwave, dishwasher were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Are locked and inaccessible to clients
Water Temperature:
Hot water temperature is tested and is within regulatory requirements.
Medications, First Aid Kit & Manual:
First Aid kit with guide is stored in the medication cabinet. Medication is stored in locked hallway cabinet
Client and Staff Files:
Kept in a locked file cabinet in hallway

Reading Material, Games, Equipment, & Materials:
The facility has materials and board games present in the facility that commensurate with their plan of operation

Component III:
Conducted at the Pre-Licensing visit, information was provided about how to operate the facility within compliance..

The Applicant demonstrated a clear, concise and comprehensive knowledge of medication protocols, documentation and preventative protocols.

The Pre-Licensing inspection has been completed. All elements verified by LPA appear to be in compliance and the facility is ready to be licensed. The license will be granted upon completion of a final review and approval from the Application Specialist.



An exit interview was conducted and a copy of this report will was emailed during the visit..
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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