347006128-9-29-2022-23-CR-TKIR-CJQSS5-20220929140723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347006128
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:07:42 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/29/2022 02:07 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, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME:	KALA HOUSE JR.		FACILITY NUMBER:	347006128
ADMINISTRATOR:	GLENDA STANLEY		FACILITY TYPE:	727
ADDRESS:	5641 W. 4TH STREET		TELEPHONE:	(916) 992-6738
CITY:	RIO LINDA	STATE: CA	ZIP CODE:	95673
CAPACITY:	4	CENSUS: 3	DATE:	09/29/2022
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator		TIME COMPLETED:	02:15 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	An annual required inspection was conducted by Licensing Program Analyst (LPA) Tana Kinder on 9/29/2022 with Facility Administrator. Community Care Licensing file, incident reports, facility roster, facility profile and complaint history were reviewed prior to visit at the agency. The licensing fees are owed on this date. This information was provided to the administrator. The Facility has a capacity of 4 and currently has 2 residents. There are 40 staff members associated to the license and 4 currently working at the Facility. LPA reviewed 4 staff files, all that were reviewed were complete and up to date. Staff files reviewed have required training hours, education, and fingerprint clearances. 3 youth files were reviewed. The youth’s needs and services plan/Individual Program Plan, Behavioral Plan (IBST) and quarterly reviews were complete and up to date. Immunization records were current. Medical consent forms were signed by authorized representative and current. Additionally, the youth’s files had a record of personal property. Personal rights, menu, license, and emergency exit plan were posted. The facility was inspected jointly with the Facility Administrator. LPA interviewed 1 client. There are 4 bedrooms and 2 bathrooms. Each bedroom has a bed for 1 client, as the facility has single occupancy bedrooms. Three bedrooms had a firm mattress, with a bed cover, sheets, blanket, and pillows. One bedroom was being repaired as a client destroyed much of the room during a behavioral episode. The common area has couches and chairs to sit in, and a TV. The facility is in good repair. There are locked cabinets in the laundry room with cleansers and detergents. Additional linen if needed for the bedrooms and the bathrooms are kept in a hall closet. Client and staff files are in locked cabinets. The passageways from the front to the back of the facility are unobstructed. LPA observed the backyard and saw a patio table with chairs and play equipment for the clients. LPA observed enough perishable/non-perishable food for 3 clients for 4 days/3 weeks. Smoke detectors are in working order. There is a carbon monoxide monitor and 2 fully charged fire extinguisher. Sharps were kept locked in the kitchen. Additional sharps are kept locked in the laundry room.

SUPERVISOR'S NAME: Rosa Rodriguez	TELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Tana Kinder	TELEPHONE: (916) 263-2000
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME: KALA HOUSE JR.	FACILITY NUMBER: 347006128
	VISIT DATE: 09/29/2022

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The kitchen was stocked with plates, utensils and drinking cups sufficient for 4 clients. The garage is set up for the client’s to play ping-pong and do crafts. The clients’ hygiene kits were stocked. A fully stocked first aid kit is kept in the laundry room.

LPA observed an emergency disaster kit for evacuation, kept in the garage.

An exit interview was conducted and discussed with the Facility Administrator. No Citations were issued.

SUPERVISOR'S NAME: Rosa Rodriguez	TELEPHONE: (916) 662-1458
LICENSING EVALUATOR NAME: Tana Kinder	TELEPHONE: (916) 263-2000
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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