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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400025
Report Date: 08/30/2023
Date Signed: 08/30/2023 12:23:47 PM

Document Has Been Signed on 08/30/2023 12:23 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:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Judieta Duenas - DSPTIME COMPLETED:
12:26 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to direct support provider Judieta Duenas who was advised of the purpose of the visit. Duenas phoned licensee and administrator Maria Cabahug. Licensees Sotero and Maria Cabahug arrived at the facility during the visit.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. One client was present during LPA's arrival and was picked up shortly by their day program.

LPA Bueno and DSP Duenas toured the exterior of the facility. The facility has no bodies of water. There is a shaded area for clients. LPA and DSP observed side gate is unlocked and free of obstruction. The facility has a working telephone for client use. The facility fire extinguishers were last inspected on 11/28/2022. DSP and LPA tested the kitchen smoke alarms and carbon monoxide detector. Licensees tested the hallway and bedroom smoke detector. All unites were in working order. A locked centralized cabinet is utilized for medications and client files. Staff files and other records are secured in a separate cabinet. Sharps, toxins, and cleaning agents are kept locked.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA and DSP observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens. LPA and DSP observed bathroom appliances were operating in safe and sanitary conditions and contained appropriate hygiene items for clients. The facility keeps a supply of hygiene provisions.
Kitchen and Dining Areas: LPA and DSP inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. The facility menu is available for review. LPA and Licensee observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The kitchen appliances, and countertop and floors were free from debris.
Common (living/activity) areas: LPA and DSP observed night lights and adequate seating in the common areas. The facility had a supply of activities for the clients.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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 2
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: 08/30/2023
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The following records were inspected:
Client Records: LPA inspected three of three client files and found that it had the required documentation including an admissions agreement, and Individual Program Plan (IPP).
Staff Records: LPA reviewed three staff files and found current first aid certifications and training verifications. The administrator certificate is current through December 2024.
Centralized Medication: LPA reviewed three of three client medications and found that the medication is being administered as prescribed. The facility does not have clients with injectable medications.

LPA also reviewed fire and earthquake drill logs, which was last conducted on 06/02/2023. Licensee verified that current personnel report and emergency disaster plan are accurate.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was discussed and a copy was provided to Licensee Maria Cabuhig at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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