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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006141
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:35:56 PM

Document Has Been Signed on 06/20/2024 03:35 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/
DIRECTOR:		JABONERO, NEILFACILITY TYPE:
735
ADDRESS:1467 W ASH AVE.TELEPHONE:
(657) 248-7120
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 4CENSUS: 3DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:21 PM
MET WITH:Anamika AhluwaliaTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by House Manager (HM) Malou Ignacio and explained the purpose of the inspection.

During the inspection LPA and HM conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with four client bedrooms, two bathrooms, and attached two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed clients watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 113.5 degrees Fahrenheit.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated March 26, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked.

Administrator (AD) Anamika Ahluwalia arrived at 2:50 p.m. to assist with the inspection. LPA reviewed three of three client files and three staff files. LPA interviewed staff and clients present.

(Cont. LIC809-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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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: 06/20/2024
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Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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