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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 11:17:57 AM

Document Has Been Signed on 04/17/2024 11:17 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
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:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Lead RBT Gustavo GutierrezTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) Muscan and Bains arrived at the facility unannounced on 04/17/2024 to conduct a Required 1- Year Inspection. LPAs met with Lead RBT Gustavo Gutierrez and explained the purpose of the visit.

LPA and Staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathrooms, kitchen, staff room, laundry area and backyard. LPA reviewed 2 client files and 2 staff files. All files contained the required paperwork. Fire drills reviewed. First Aid kit was fully stocked. Water temperature is within compliance. All cleaning chemicals and laundry supplies were kept locked. Fire extinguisher is ready for use. In the areas toured no immediate health, safety, or personal rights violations were observed.

Facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
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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