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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700829
Report Date: 08/14/2024
Date Signed: 08/14/2024 11:55:21 AM

Document Has Been Signed on 08/14/2024 11:55 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: 3DATE:
08/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Shoa JohnsonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 8/14/24 to do a health and safety check. LPA met with Administrator, Shoa Johnson and explained the purpose of the visit.
During today's visit, LPA learnt that one client was in hospital, one was attending school and two were present at the facility during visit.

During today's visit, the Department checked the food supply and did a brief walk through the facility with administrator. No concerns noted.

No citations were issued per Title 22 Regulations.

Exit interview conducted and copy of the report left at facility.




SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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