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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:05:31 AM

Document Has Been Signed on 02/10/2023 11:05 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:KALA HOUSEFACILITY NUMBER:
342700829
ADMINISTRATOR:SHOAAXUM JOHNSONFACILITY TYPE:
738
ADDRESS:6804 SANTA JUANITA AVETELEPHONE:
(916) 542-7858
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 4CENSUS: 4DATE:
02/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Shoaaxum Johnson, AdministratorTIME COMPLETED:
10:15 AM
NARRATIVE
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On 02/10/2023, Licensing Program Analyst (LPA) Bains arrived at the above to conduct a Case Management visit regarding an incident that occurred on 02/03/23. LPA met with Administrator Shoa Johnson and explained reason for visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened upon entry by facility staff.

Alta California Regional Center Special Incident Report submitted by facility on 02/05/23 to CCL stated that Staff (S2) was passing medications in the evening on 02/03/23 and found a medication error for resident (R1). S2 notified Administrator of medication error.

Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive 1 tab of Trazodone 100mg for 02/03/23 for evening/night but facility missed that medication for R1. S1 had prepared the PM medication ON 02/03/23 and it was verified by the lead on duty. It was determined the S1 had followed protocols while preparing the medications, however, failed to prepare Trazadone 100 mg, the final medication on the MAR. Facility notified R1s physician, CCL, ALTA and other agencies regarding this Medication Error on 02/05/23.


Deficiency is cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

Exit interview conducted. Appeal rights provided. Copy of the report left at facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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 02/10/2023 11:05 AM - It Cannot Be Edited


Created By: Talwinder Bains On 02/10/2023 at 09:58 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: KALA HOUSE
FACILITY NUMBER: 342700829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/11/2023
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee/Administrator agreed to submit a self-certification in regard to providing medication training for all staff who administers medication and submit proof to LPA by POC date- 02/11/2023.
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Based on observation and record review from the facility, On 02/03/23, R1 was supposed to receive 1 tab of Trozodone 100mg in evening/night shift but facility did not gave that medication to R1 and R1 missed the medication. This poses an immediate health and safety risk to residents in care.
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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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023


LIC809 (FAS) - (06/04)
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