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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413139
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:35:11 AM

Document Has Been Signed on 12/07/2023 11:35 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KALIA HOMEFACILITY NUMBER:
366413139
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:902 N. LINDEN AVETELEPHONE:
(909) 429-4418
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 3DATE:
12/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Abraham Castro, DSP * Sydnee Musgrave, DSPTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Kalia Home, Adult Residential Facility unannounced to conduct a case management visit. This case management visit is in response to an Incident Report, (IR) submitted to the Community Care Licensing Office by the Inland Regional Center on 12/1/2023. LPA was greeted and granted entry into the facility by Direct Support Provider, Abraham Castro, (S1) LPA introduced self and stated purpose of the visit. S1 contacted the Administrator, Fernando Melendez. LPA spoke with Administrator over the phone and stated the purpose of the visit.

During today's visit LPA conducted a walk through of the facility, staff and resident interviews and collected pertinent documents. According to the IR, on 11/29/23 R1 asked staff for a cup of water. Staff advised R1 to get water from the kitchen. Instead, R1 went into the staff office, took the staff keys from a hook on the wall, then used the keys to access the centrally located medications. Accessed her own medications and took 18 doses of such. Staff and resident interviews revealed consistent statements. The facility staff office door was shut, but door left unlocked; giving residents access to the centrally stored medications. According the Administrator, the facility held a staff meeting on the following date and made changes to improve its protocol for securing the centrally medications. An In-Service Training is scheduled for 12/8/23 to further address the matter. Additional training will be provided to the staff members present and involved during the incident. During walk through, LPA made no observations of imminent health, safety or hazardous concerns inside the facility.

Based on observations and interviews made during today's visit, one, (1) deficiency will be cited per Title 22, Division 6, of the California Code of Regulations. Please see LIC809-D

An exit interview was conducted where this report was reviewed, discussed and then provided to the facility representative.




SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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
Document Has Been Signed on 12/07/2023 11:35 AM - It Cannot Be Edited


Created By: Amber Coleman On 12/07/2023 at 11:11 AM
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: KALIA HOME
FACILITY NUMBER: 366413139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2023
Section Cited
CCR
80075(k)(1)

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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally
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Administrator agrees to provide additional medication management training to the staff members involved. Administrator also agrees to provide verification of that training as well as the scheduled In-Service Training about Medication Management on 12/8/23. Administrator also agrees to provide verifica-
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stored medication.
This requirement was not met as evidenced by: Based on staff & resident interviews, the Licensee/Administrator did not ensure centrally stored medications were kept secure and inaccessible which poses an immediate Health, Safety & Personal Rights risk to persons in care.
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tion to the Community Care Office on 12/8/23.
To be submitted with the verification is a statement of understanding of the regulation by way of a LIC9098 Form.

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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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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