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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408118
Report Date: 08/26/2021
Date Signed: 08/26/2021 02:10:02 PM

Document Has Been Signed on 08/26/2021 02:10 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
RIVERSIDE, CA 92507
FACILITY NAME:KIRBY HOMEFACILITY NUMBER:
366408118
ADMINISTRATOR:CRISELDA MIQUELFACILITY TYPE:
735
ADDRESS:12658 15TH STREETTELEPHONE:
(909) 795-9341
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 6CENSUS: 4DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Criselda Miguel, AdministratorTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 11:20 AM, LPA was met by Administrator Criselda Miguel and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as four (4) residents. There are currently no cases of COVID-19 but one client exposed within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions. All staff and residents are fully vaccinated . 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 residents for COVID-19, when and how to isolate/quarantine residents, 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 resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

(CONTINUED ON 809-C).
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
RIVERSIDE, CA 92507
FACILITY NAME: KIRBY HOME
FACILITY NUMBER: 366408118
VISIT DATE: 08/26/2021
NARRATIVE
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Based on the observations made during today’s visit, there are two (2) deficiencies cited per Title 22, Division 6, of the California Code or Regulations. LPA prepared this report offsite and returned to the facility and met with Administrator Criselda Miguel and an exit interview to review this report was conducted and a copy of this report was provided
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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Document Has Been Signed on 08/26/2021 02:10 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 08/26/2021 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KIRBY HOME
FACILITY NUMBER: 366408118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed small insects on kitchen counter top and bedbug product, the licensee did not comply with the section cited above in taking measures to keep the facility free of insects which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
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Licensee will contact Pest Control Company and will email LPA the receipt of services rendered and received by POC due date September 16, 2021.
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's interview with Administrator, the licensee did not comply with the section cited above in reporting the insects in the facility to CCLD within the seven days of occurence. Administrator stated insects have been for the last 30 days, failure to report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
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Licensee will do a statement self certifying that Licensee will read and acknowledge the section for CCR 8001(b) and email to LPA by POC due date September 16, 2021
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


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