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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881390
Report Date: 03/12/2025
Date Signed: 03/12/2025 12:09:47 PM

Document Has Been Signed on 03/12/2025 12:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DNM KALEIFACILITY NUMBER:
331881390
ADMINISTRATOR/
DIRECTOR:		ARROYO, NAOMIEFACILITY TYPE:
735
ADDRESS:3077 KALEITELEPHONE:
(951) 238-1371
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 4CENSUS: 4DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Licensee, Wilton MilesTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with staff and was later met by Licensee, Wilton Miles and Administrator Naomie Arroyo who were informed of the purpose of the visit. At the time of the visit there was (4) staff and (1) client present.

The facility is a two story home with (4) bedrooms and (3) bathrooms, and (1) staff office. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed the hand washing stations, hand hygiene and personal hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature was read at 106F.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DNM KALEI
FACILITY NUMBER: 331881390
VISIT DATE: 03/12/2025
NARRATIVE
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Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (5) staff files and training. All staff have criminal clearance and updated training along. (1) staff did not have CPR or first aide training, and (2) staff did not have their physical and (1) staff did not have TB test documented at the time of the visit. The facility was cited for not having the staff records. (4) client files were reviewed, (2) residents did not have rental amounts on their admission agreements from their placement agency. This was documented on a technical advisory form for staff to document the rental amount.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications for (4) client and found all medication listed on MARS and accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill 1/15/2025, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies including first aid kits.

An exit interview was conducted where this report was reviewed and provided along with appeal rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/12/2025 12:09 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/12/2025 at 11:36 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: DNM KALEI
FACILITY NUMBER: 331881390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview the licensee did not comply with the section cited above with (2) of (5) staff who did npt have TB test or documented physical which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The licensee agreed to send the required forms signed by a physican for the (1) staff by the POC due date. The licensee agreed to send a self certified statment on their plan to ensure the staff files are audited for completness.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/12/2025 12:09 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/12/2025 at 11:36 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: DNM KALEI
FACILITY NUMBER: 331881390

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, the licensee did not comply with the section cited above with (1) of (5) staff who did not have CPR training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The licensee agreed to have the staff CPR trained by the POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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