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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 02/22/2023
Date Signed: 02/22/2023 10:17:26 AM

Document Has Been Signed on 02/22/2023 10:17 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
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:
02/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Shoa Johnson TIME COMPLETED:
10:30 AM
NARRATIVE
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On 02/22/2023, Licensing Program Analysts (LPAs) Bains and Muscan arrived at the above to conduct a Case Management visit regarding an incident that occurred on 02/10/23. LPAs met with Administrator Shoa Johnson and explained reason for visit. Prior to initiating the annual inspection, LPAs 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. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical masks.

Alta California Regional Center Special Incident Report submitted by facility on 02/13/23 to CCL stated that at 9pm on 02/11/23, the Administrator was notified by the lead on duty that there was a missing signature for R1's 8pm medications for 02/10/23, The administrator followed up with the lead from that day and they stated that they had recalled the medications being passed. On 02/11/23, the Administrator went to the facility to make sure the medications were given. and ensure the information given was accurate. The Administrator reviewed the MAR and the medication bubble packs and concluded that the medications- Cloridine 0.2mg-1tab, Gabapentin 600mg-1tab , Melatonin 3mg-2 tabs , Olanzapine 10mg-1tab were NOT given on 02/10/23 to R1 as prescribed by R1s physician.

Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive all these medications for 02/10/23 for evening/night but facility missed that medication for R1. It was determined the S1 had followed protocols while preparing the medications, however, failed to prepare the Cloridine 0.2mg-1tab, Gabapentin 600mg-1tab , Melatonin 3mg-2 tabs , Olanzapine 10mg-1tab as final medication on the MAR. Facility notified R1s physician, CCL, ALTA and other agencies regarding this Medication Error on 02/13/23.

Deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Immediate Civil penalty of $250.00 was assessed on LIC421FC today due to repeat violation of the same regulation within 12 months. The report was reviewed, appeal rights and a copy of this report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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 02/22/2023 10:17 AM - It Cannot Be Edited


Created By: Talwinder Bains On 02/22/2023 at 10:06 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: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2023
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- 02/23/2023.
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Based on observation from the facility, on 02/10/23, R1 was supposed to receive Cloridine 0.2mg-1tab, Gabapentin 600mg-1tab , Melatonin 3mg-2 tabs , Olanzapine 10mg-1tab in evening/night shift but facility did not give 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: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023


LIC809 (FAS) - (06/04)
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