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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006141
Report Date: 06/06/2023
Date Signed: 06/07/2023 07:51:46 AM

Document Has Been Signed on 06/07/2023 07:51 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
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:
(657) 248-7120
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 3DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Anamika Ahluwalia & Anish GoreTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 Year evaluation. LPA was greeted and granted entry by Staff Dorcas Mbugua and reason for visit was explained. Licensee Anamika Ahluwalia and Administrator Anish Gore arrived shortly after. LPA confirmed Administrator has a current certificate, which expires on 11/23/2024.

The facility currently has 3 clients; 2 present during today's visit. LPA Martinez, along Licensee Ahluwalia and AD Gore conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following: Facility is a one story house with 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, laundry room and an attached two car garage that is used for storage and lounging. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. The back yard has patio furniture and a huge umbrella for clients and visitors use.

Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Facility does not have live-in staff. Bathrooms were clean, faucets, showers and toilets were operational. Hot water temperature in client bathroom was within regulatory requirements. Linen and hygiene supplies were stocked in hallway cabinet. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is clean and organized. Hygiene supplies are provided for number of client's in care. Food supply was noted to be in sufficient quantities to meet the regulatory requirements of a 2-day perishables and 7-day non-perishables. Emergency food and water supply is available. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguisher were charged and mounted, last charged on 04/11/2023. Fire drills are conducted once a month and LPA verified last Fire Drill was conducted on 06/01/2023. Stove burners, microwave, dishwasher, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Medications are centrally stored in a locked hallway cabinet. Medications reviewed appear to have been dispensed accurately.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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: 06/06/2023
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First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan is posted.

LPA reviewed three client files and two staff file. The clients P&I records were reviewed, LPA observed that an individual log is maintained for each client. All monies are accounted for and logs were kept to date.

Based on observations made, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted with AD and a copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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