331800202-12-14-2023-18-AS-CNWE-CYHQMM-20231214111746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800202
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:17:52 AM

Document Has Been Signed on 12/14/2023 11:17 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KALPESH HOME		FACILITY NUMBER:	331800202
ADMINISTRATOR:	CHURCH, CINDY		FACILITY TYPE:	735
ADDRESS:	944 KALPESH DRIVE		TELEPHONE:	(951) 487-1873
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92583
CAPACITY: 6		CENSUS: 4	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Cindy Church, Licensee/ Administrator		TIME COMPLETED:	11:25 AM

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On 12/14/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Licensee/ Administrator, Cindy Church who was informed of the purpose of the visit. At the time of visit there was one #1 staff and #1 residents present. LPA was informed the other three #3 residents are at the Day Program. LPA toured the facility inside and out with Cindy Church.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lids. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 73 degrees Fahrenheit.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication: Medications were labeled and stored in separate bins inside of a locked medication cabinet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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Document Has Been Signed on 12/14/2023 11:17 AM - It Cannot Be Edited

Created By: Chinwe Nwogene On 12/14/2023 at 10:54 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KALPESH HOME	FACILITY NUMBER: 331800202
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the bathroom sinks hot water temperature at 127 degree Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	LPA observed the Licensee adjust the hot water heater temperature. Licensee stated a picture of the adjusted hot water temperature will be provided to LPA by the POC due date 12/22/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Chinwe Nwogene

LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KALPESH HOME	FACILITY NUMBER: 331800202
	VISIT DATE: 12/14/2023

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Continued from LIC809.

Bathroom: LPA toured two #2 hall bathrooms and observed bathrooms to be clean and equipped with grab bar and non-skid mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 127 degrees Fahrenheit which is above regulatory standard (citation will be issued).

Bedroom: LPA toured four #4 out of #4 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. Night lights were maintained throughout the facility.

Garage: LPA tour the garage and observed garage to be clean.

Laundry: Washing machine and dryer are all in good repair and sufficient for the census. Cleaning supplies are stored away in a closet, inaccessible to clients.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and freezer are large enough to accommodate required perishable foods.

Records: All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 6/6/2024.

Interview: One staff and one resident were interviewed.

Therefore, based on the observations made during today’s visit, one #1 deficiency will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted, and this reported was provided along with appeal rights to Cindy Church.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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