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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400025
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:56:06 PM

Document Has Been Signed on 06/20/2022 01:56 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:KC FAMILY HOMEFACILITY NUMBER:
366400025
ADMINISTRATOR:CABAHUG, MARIA WENELIZA D.FACILITY TYPE:
735
ADDRESS:7470 TAMARIND AVENUETELEPHONE:
(909) 357-1430
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee/AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/20/2022 at 12:45 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Judieta Duenas and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator/Licensee Maria Weneliza Cabahug was contacted and informed of the visit. Staff Duenas reported that they have three (3) clients at the facility. Licensee/Administrator Cabahug arrived during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Cabahug. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE, LPA Brown went over the various recommended training for facility staff with Licensee/Administrator Cabahug in relation to COVID-19 and Licensee/Administrator Cabahug informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Licensee/Administrator Cabahug informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, LPA Brown observed all clients andall staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.
**** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KC FAMILY HOME
FACILITY NUMBER: 366400025
VISIT DATE: 06/20/2022
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The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 06/20/2022 at 01:15 PM, LPA Brown observed all staff have dose 1, dose 2 and booster. Licensee/Administrator Cabahug showed proof of vaccinations/booster record to LPA Brown during the visit.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations.

An exit interview was conducted with Licensee/Administrator Maria Weneliza Cabahug and a copy of this report (LIC809) and LIC9102 TA Advisory Note were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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