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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 04/17/2024
Date Signed: 04/17/2024 10:49:34 AM

Document Has Been Signed on 04/17/2024 10:49 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KALA HOUSEFACILITY NUMBER:
342700829
ADMINISTRATOR/
DIRECTOR:		SHOAAXUM JOHNSONFACILITY TYPE:
738
ADDRESS:6804 SANTA JUANITA AVETELEPHONE:
(916) 542-7858
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 4CENSUS: 4DATE:
04/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Lead RBT,Gustavo GutierrezTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 04/17/24, Licensing Program Analysts (LPAs) Bains and Muscan arrived at the above to conduct a Case Management visit regarding an incident that occurred on 07/15/23 and 04/06/24 for residents R1 and R2 regarding medication error. LPAs met with Lead RBT,Gustavo Gutierrez and explained reason for visit.

Incident for R1- Alta California Regional Center Special Incident Report submitted by facility on 07/17/23 to CCL stated that at approximately 11am, while auditing medications, staff discovered that resident, R1 received only one (1) pill of Divalproex at 500mg on the morning of 7/15/23. This dosage was supposed to be given in two (2) pills instead of only one (1), resulting in ½ dosage of one medication given the morning of 7/15/23. The administrator reviewed the pill pack and confirmed the medication error.

Incident for R2- Alta California Regional Center Special Incident Report submitted by facility on 04/06/24 to CCL stated that At approximately 2:00 AM on 4/06/2024, staff was conducting a medication audit when it was noticed that resident, R2 did not receive the 12 :00 pm dose of Gabapentin, 600mg as ordered by R2s physician.

Facility notified R1s and R2s physician, CCL, ALTA and other agencies regarding these Medication Error.

Based on above information, it was determined that facility did not administer medications for R1 and R2 as ordered by their physician, therefore deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D.

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: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 10:49 AM - It Cannot Be Edited


Created By: Talwinder Bains On 04/17/2024 at 10:16 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KALA HOUSE
FACILITY NUMBER: 342700829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
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 regarding this regulation and send this document to LPA by 04/18/24. Furthermore, facility will do monthly all staff training regarding medication administration till June 2024 and will send monthly training documents to LPA.
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Based on record review from the facility, it was determined that facility did not administer the medication for residents, R1 and R2 on 07/15/23 and 04/06/24 as ordered by their physician. 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: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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