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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366400025
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:33:47 PM

Document Has Been Signed on 09/11/2024 03:33 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KC FAMILY HOMEFACILITY NUMBER:
366400025
ADMINISTRATOR/
DIRECTOR:		CABAHUG, MARIA WENELIZA D.FACILITY TYPE:
735
ADDRESS:7470 TAMARIND AVENUETELEPHONE:
(909) 357-1430
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 3DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Maria Cabahug, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:42 PM
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Licensing Program Analyst (LPAs) La Vette Farlow and MIchelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPAs met with Licensee, Maria Cabahug, and introduced themselves and stated purpose of the visit. LPAs were informed that 2 clients were at the day program and 1 present in the home.

The facility has 3 bedrooms, 2 bathrooms, office, kitchen, dining area, family room, living room, laundry room inside the attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPAs completed a walk through of facility, review of records, medication and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 116.6 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. Posters such as; the personal rights, CCL complaint poster and disaster plans were posted in the office. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were observed in secure cabinets and inaccessible to clients. The facility had emergency kits in the garage for clients in care. There are no firearms, ammunition, pool or bodies of water in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KC FAMILY HOME
FACILITY NUMBER: 366400025
VISIT DATE: 09/11/2024
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Yards/Outside: LPAs observed one shaded patio, a side gates with self-latching handle on the left side and right side of the house that leads into the backyard, fruit tree and vegetables growing in the garden. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPAs reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed Licensee and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. P & I funds and medications were audited and appeared to be managed appropriately. The facility last conducted a disaster drill in August 6, 2024. LPAs observed that the Emergency Disaster Plan had not been reviewed and updated since 1/4/2022, technical violation issued.

No deficiencies were cited during this visit, one (1) technical violation issued. An exit interview was conducted where this report LIC809, LIC809C and LIC 9102TB were discussed and copies were provided to the Licensee, Maria Cabahug.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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