366413139-7-31-2023-56-AS-ACON-CU9PQ7-20230731113040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366413139
Report Date: 07/31/2023
Date Signed: 07/31/2023 11:30:47 AM

Document Has Been Signed on 07/31/2023 11:30 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 HOME		FACILITY NUMBER:	366413139
ADMINISTRATOR:	PENDING		FACILITY TYPE:	735
ADDRESS:	902 N. LINDEN AVE		TELEPHONE:	(909) 429-4418
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY: 4		CENSUS: 3	DATE:	07/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Cynthia Santos- Staff		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Kalia Home Adult Residential Facility unannounced to conduct an Annual Inspection. Staff member, Cyntha Santos answered the door and greeted LPA. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided a space to work. Staff notified Administrator, Fernando of LPA's visit and arrived at the facility. The facility included 5 bedrooms, 1 staff room, 2 bathrooms, a kitchen, dining area, living room, attached garage, and backyard. The facility is a Specialized Level facility vendorized by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following: 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. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, sufficient lighting and personable touches. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept inaccessible to residents in the securely in the staff office. Medications were locked and inaccessible to residents in the staff office as well. The facility had emergency and first aid kits readily available for clients 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 for number of residents residing in the facility. Facility has a 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: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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 3

Document Has Been Signed on 07/31/2023 11:30 AM - It Cannot Be Edited

Created By: Amber Coleman On 07/31/2023 at 11:18 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: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in 3 out of 3 resident files were observed to not have up to date Physician's Report which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator agrees to have the residents evaluated by a doctor to have their LIC602 (Physician's Report) updated. Administrator agrees to have these completed within 30 business days and submit verification to the Community Care Licensing.

Section Cited

Modifications to Needs and Services Plan


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 07/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KALIA HOME	FACILITY NUMBER: 366413139
	VISIT DATE: 07/31/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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: LPA reviewed 3 residents files for admission agreements, updated physician reports, and needs and services plans. LPA observed that three out of three of the residents will need their Physician's Reports completed as they were out of compliance. LPA also reviewed 3 staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. The facility last conducted a disaster drill on 6/6/23.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

Page: 1 of 1