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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603693
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:08:19 PM

Document Has Been Signed on 05/07/2024 04:08 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:KALEA HOUSEFACILITY NUMBER:
374603693
ADMINISTRATOR/
DIRECTOR:		LAURA GARCIAFACILITY TYPE:
735
ADDRESS:1312 SAN MIGUEL AVENUETELEPHONE:
(619) 303-9108
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 4CENSUS: 3DATE:
05/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Laura Garcia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Tiffany Holmes conducted a Case Management - Other visit. LPA was greeted and allowed entry into the facility by Laura Garcia, Administrator. LPA stated the purpose of the visit was to follow up on a death of a client.

During today's visit, LPA briefly toured the facility, requested records, and conducted interviews. On 05/06/24, Community Care Licensing received a death report for Client #1 (C1). The report stated on 04/29/2024 C1 having difficulty breathing and was choking. The family did not want to intubate and so a DNR was signed and they decided to do palliative care and placed C1 on hospice. C1 passed on 05/02/2024.

Once the facility staff receives a death certificate they will provide it to the department.

No deficiencies were issued today.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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