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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413139
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:16:43 PM

Document Has Been Signed on 07/27/2021 12:16 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:KALIA HOMEFACILITY NUMBER:
366413139
ADMINISTRATOR:ARASTU, SAMEEFACILITY TYPE:
735
ADDRESS:902 N. LINDEN AVETELEPHONE:
(909) 429-4418
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 4DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jay Bujanda - AdministratorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Jay Bujanda and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Jay Bujanda, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, as well as hand soap and paper towels (which are kept in their bedrooms) and there is a hand washing guide posted above the sink in the bathroom for residents to reference. LPA Colvin additionally observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information.

LPA Colvin requested to inspect the facility's Personal Protective Equipment (PPE) supply, which is stored in a file cabinet in the hallway. LPA Colvin observed the facility to have a 30-day supply of gloves, masks, and sanitizer, and isolation gowns. LPA Colvin went over the various recommended training for facility staff with Administrator Jay Bujanda in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and the Administrator informed LPA Colvin that at this time staff have not been fit tested. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, most residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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
RIVERSIDE, CA 92507
FACILITY NAME: KALIA HOME
FACILITY NUMBER: 366413139
VISIT DATE: 07/27/2021
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LPA Colvin will be providing Administrator Jay Bujanda with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their staff members. Administrator Jay Bujanda informed LPA Colvin that they have continuing to test their staff members regularly for COVID-19. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Jay Bujanda informed LPA Colvin that staff have been continuing to check the residents’ temperature and other symptoms daily. Staff are additionally being screened daily as well as any visitors to the facility. No deficiencies cited.

An exit interview was conducted with Administrator Jay Bujanda and a copy of this report and LIC9102 TA Advisory Note was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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