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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413139
Report Date: 04/04/2025
Date Signed: 04/04/2025 10:18:44 AM

Document Has Been Signed on 04/04/2025 10:18 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 - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator Fernando MelendezTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 04/04/2025 at 09:15 AM, Licensing Program Analyst (LPA), Melody Brown, visited the facility to deliver the investigative findings for the allegation of staff inappropriately touched a client while in care reported in Special Incident Report (SIR) submitted to San Bernardino Adult and Senior Care (ASC) Regional Office (RO). LPA Brown identified herself and discussed the purpose of the visit with Administrator Fernando Melendez.

The investigation of the allegation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The allegation indicates staff inappropriately touched a client while in care. Interview with Client #1 (C1) indicated that Staff #3 (S3) inappropriately touched C1 while in care. During the Department investigation, it was reported that in 06/29/2024, S3 drove C1 to work and during the transportation, S3 continued their conversation of having intimate relationship with C1 then S3 utilized S3’s right hand, reached into C1’s shirt and inappropriately touched C1. Department staff revealed that per review of the police report, C1 statement was consistent with the statement C1 provided to Department staff. In addition, the Department staff interview with Staff #4 (S4) revealed S3 failed to set boundaries with C1 who sought constant attention from others and would sit and talk to C1 during S3’s shift. Moreover, Department staff indicated that interview with Staff #1 (S1) revealed their internal investigation exposed S3 failed to follow the facility’s procedures as S3 communicated with C1 via S3’s personal email and S3 admitted that C1 sat in the front seat of the facility vehicle when S3 transported C1 to work in 06/29/2024. Furthermore, the Department staff interview with S3 revealed that S3 did not make an admission/confession to Department staff however, S3 statement revealed inconsistencies.

Based on the Department’s observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the allegation of staff inappropriately touched C1 while in care is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC809D. ***Continuation in LIC809C***

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Melody Brown
LICENSING PROGRAM ANALYST SIGNATURE: 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 3
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: KALIA HOME
FACILITY NUMBER: 366413139
VISIT DATE: 04/04/2025
NARRATIVE
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An exit interview was conducted where this report, LIC809, LIC809D, and Appeal Rights were discussed and provided to Administrator Fernando Melendez.
NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Melody Brown
LICENSING PROGRAM ANALYST SIGNATURE:

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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 10:18 AM - It Cannot Be Edited


Created By: Melody Brown On 04/04/2025 at 09:00 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 A
04/05/2025
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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Licensee stated they immediately placed Staff #3 (S3) on administrative leave pending investigation and to train all staff on CCR 80065(a) and submit proof of all staff training log to LPA Brown by the Plan of Correction (POC) due date.
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Based on interviews and records review, the Licensee did not comply with the section cited above by allowing Staff #3 (S3) to inappropriately touched Client #1 (C1) on 06/29/2024 while S3 drove C1 to work which pose immediate health, safety, and personal rights risks to clients in care.
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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.
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)
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