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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881028
Report Date: 04/18/2023
Date Signed: 04/18/2023 12:08:26 PM

Document Has Been Signed on 04/18/2023 12:08 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MENTAL WELLNESS KS INC.FACILITY NUMBER:
331881028
ADMINISTRATOR:MCLAUGHLIN, ERICFACILITY TYPE:
772
ADDRESS:502 N. CERRITOS RDTELEPHONE:
(310) 402-4911
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 0DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Gus Tarrant, Program ManagerTIME COMPLETED:
12:15 PM
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On 4/18/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Program Manager, Gus Tarrant who was informed of the purpose of visit. At the time of visit there was 0 staff and 0 residents present. LPA toured the facility inside and out with Gus Tarrant.

Tour included:

Kitchen; LPA toured the kitchen and observed no food available. Gus stated facility currently has no clients and have had no client in care for over a year. Gus stated 7-day supply of non-perishable and 2-day supply of perishable foods will be available when clients are admitted. LPA observed utensils and dishware are sufficient. The refrigerator and stove are in working order. Sharps will be stored in the medication room, available only to authorized individuals. Trash can has tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 38 degrees Fahrenheit and Freezer was measures at -16 degrees Fahrenheit.


Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 74 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.

Medications; Due to no clients in care, no medication was observed. LPA observed the first aid kit to be complete.



Continue on LIC809-C
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MENTAL WELLNESS KS INC.
FACILITY NUMBER: 331881028
VISIT DATE: 04/18/2023
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Continued from 809

Bathroom; LPA toured three #3 out of #3 bathrooms in the facility and observed bathroom to be clean. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 114 degrees Fahrenheit

Bedroom; LPA toured Three #3 out of #3 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting.

Laundry; LPA toured the laundry room and observed laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for approved census. Cleaning supplies will be stored away in the laundry room, 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 gates remain unlocked. The facility has a pool that is covered by a mesh security cover. The security cover has spring-loaded straps that connect to the cover and are anchored into the concrete to hold it in place.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility.

Interview; No interview was conducted because there was no client and no staff present.

No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Gus Tarrant.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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