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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408118
Report Date: 08/19/2023
Date Signed: 08/19/2023 11:43:05 AM

Document Has Been Signed on 08/19/2023 11:43 AM - 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:KIRBY HOMEFACILITY NUMBER:
366408118
ADMINISTRATOR:CRISELDA MIGUELFACILITY TYPE:
735
ADDRESS:12658 15TH STREETTELEPHONE:
(909) 795-9341
CITY:YUCAIPASTATE: CAZIP CODE:
92399
CAPACITY: 6CENSUS: 3DATE:
08/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Criselda Miguel, Licensee/Administrator TIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a comprehensive annual inspection. LPA Nickolas met with Licensee/Administrator Criselda Miguel and explained the purpose of the visit. Today’s inspection included a facility tour, record review, and interviews with staff and residents.

The facility is six (6) bedrooms and four (4) bathrooms of which three (3) bedrooms and two (2) are designated for clients in care. The facility also has kitchen/dining area, living area, sun room, pantry room, and detached garage. Licensed capacity is six (6).

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 76 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Nickolas' observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation between 109.5 and 111.5 degrees. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Nickolas tested during the visit. The facility has one (1) charged fire extinguishers, that are serviced annually by the state Fire Marshal. LPA Nickolas observed personal rights posters, Licensing documents, and the disaster plan posted throughout the facility. LPA Nickolas observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Nickolas observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members and volunteers working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2023
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: KIRBY HOME
FACILITY NUMBER: 366408118
VISIT DATE: 08/19/2023
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Record Review: LPA Nickolas reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. Medications were audited randomly and appeared to be dispensed appropriately by staff members. LPA Nickolas reviewed one (1) staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided Miguel.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023
LIC809 (FAS) - (06/04)
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