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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 05/31/2022
Date Signed: 05/31/2022 04:27:16 PM

Document Has Been Signed on 05/31/2022 04:27 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
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) 216-8680
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 4CENSUS: 3DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Shoaaxum Johnson, AdministratorTIME COMPLETED:
04:30 PM
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On 5/31/22 at 1:20 PM Licensing Program Analyst (LPA) Praveen Singh arrived unannounced to conduct an annual required inspection. Prior to initiating the 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. LPA contacted licensee and spoke with Michelle Wagner and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA met with Administrator Shoaaxum Johnson and discussed the purpose of visit. At approximately 2:00 p.m., Intake and Client Service Manager, Tanya Nalley, arrived to join the annual inspection visit. Facility has census of 3.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen & backyard.. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled at every 30 days. Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiency cited during the inspection. Exit interview conducted and copy of the report provided via email to Administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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