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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 05/07/2024
Date Signed: 05/07/2024 01:01:10 PM

Document Has Been Signed on 05/07/2024 01:01 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
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:
05/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Administrator, Shoa JohnsonTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 05/07/24, Licensing Program Analysts (LPAs) Bains and Muscan arrived at the above to conduct a Case Management visit regarding an incident that occurred on 04/24/24 for resident R1 regarding medication error. LPAs met with Administrator, Shoa Johnson and explained reason for visit.

Incident for R1- Alta California Regional Center Special Incident Report submitted by facility on 04/25/24 to CCL stated that on 04/24/24 at approximately 4pm, staff gave Clonidine 0.2mg medication to resident, R1 by mistake. Record review indicated that R1 has order for Clonidine 0.1 mg daily at 8pm but staff administered wrong dose of medication (Clonidine) to R1 and at wrong time. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error.

Based on above information, it was determined that facility administered wrong medication and at wrong time for R1 which was Not 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. 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: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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 05/07/2024 01:01 PM - It Cannot Be Edited


Created By: Talwinder Bains On 05/07/2024 at 09:44 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: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
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 05/08/24. Furthermore, facility will do all staff training regarding medication administration twice a month till July 2024 and will send training documents to LPA.
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Based on record review from the facility, it was determined that facility administered wrong medication to resident, R1 on 04/24/24 which was not ordered by R1s 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: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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