<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 05/23/2022
Date Signed: 05/23/2022 02:05:26 PM

Document Has Been Signed on 05/23/2022 02:05 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: 4DATE:
05/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Michael Christopher, Lead StaffTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Praveen Singh arrived to conduct an unannounced Case Management inspection in relation to the Department receiving a priority 2 complaint. 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. In addition, LPA contacted Administrator 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: N95 mask. LPA met with Lead staff Michael Christopher and discussed the purpose of the visit.

During the inspection, LPA toured the interior of the facility including but are not limited to: common areas, resident bedrooms, bathrooms, kitchen and laundry area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA verified with Lead Staff that there is no shortage of food supply and the facility is well equipped with personal protective equipment (PPE).

No deficiencies cited during inspection. Exit interview conducted and copy of this report emailed to Administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1