<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413139
Report Date: 04/04/2025
Date Signed: 04/04/2025 10:22:59 AM

Document Has Been Signed on 04/04/2025 10:22 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:KALIA HOMEFACILITY NUMBER:
366413139
ADMINISTRATOR/
DIRECTOR:		PENDINGFACILITY TYPE:
735
ADDRESS:902 N. LINDEN AVETELEPHONE:
(909) 429-4418
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 3DATE:
04/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Fernando MelendezTIME VISIT/
INSPECTION COMPLETED:
10:30 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
On 04/04/2025 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a case management visit. LPA Brown was greeted and granted entrance by a staff member and LPA Brown met with Administrator Fernando Melendez. At the time of the visit, there were no clients at the home, and two (2) staffs present.

During the Department staff investigation, Department staff observed Staff #3 (S3) was not listed on the Personnel Report. Department staff interview with S3 revealed that S3 began working at the facility on 09/14/2023. Staff #1 (S1) reported to Department staff that S3 was probably listed on the other facility operated by the same licensee. Administrator Fernando Melendez was informed that deficiency will be issued. Also, per records review, the facility was cited for the same violation 80019 Personnel Requirements(e)(3) on 08/22/2024 which is within the 12-month period. Therefore, a Civil Penalty will be assessed with the amount of $3,000.00 and will continue to be assessed of $100.00 per day per citation until corrected for not transferring S3 criminal background clearance to the facility prior to employment.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Administrator Fernando Melendez.

Efren Malagon
Melody Brown
DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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 04/04/2025 10:22 AM - It Cannot Be Edited


Created By: Melody Brown On 04/04/2025 at 08:46 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
, CA 92507

FACILITY NAME: KALIA HOME
FACILITY NUMBER: 366413139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2025
Section Cited

1
2
3
4
5
6
7
80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing...(3) Request a transfer of a criminal record clearance...This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and records review, the Licensee did not comply with the section cited above by not transferring S3 criminal background clearance to the facility prior to employment on 09/14/2023 which poses a potential health, safety, and personal rights risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Melody Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2