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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603835
Report Date: 02/26/2024
Date Signed: 02/26/2024 11:53:11 AM

Document Has Been Signed on 02/26/2024 11:53 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:KP DISABILITY SERVICE 2FACILITY NUMBER:
374603835
ADMINISTRATOR:POLLARD, KIMFACILITY TYPE:
735
ADDRESS:8350 GOLDEN AVENUETELEPHONE:
(619) 931-8129
CITY:LEMON GROVESTATE: CAZIP CODE:
91945
CAPACITY: 6CENSUS: 6DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brain Bi, House Manager
Kim Pollard, Adminstrator		TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Renita Hall, conducted an unannounced Required 1 year Annual Visit. LPA was allowed entry by Brain Bi, House Manager. LPA identified herself and disclosed the purpose of the visit with the House Manager. The visit was later joined by Kim Pollard, Administrator.

Physical Environment:  The facility from any safety hazards. Adequate lighting and ventilation were observed in all areas of the facility. All necessary safety equipment, such as fire extinguishers and emergency exits, were present and in working condition. The facility's outdoor spaces were accessible to residents.

Staffing and Training:  The facility had a sufficient number of qualified staff members to meet the needs of the residents.  The staff member was observed to be professional, courteous, and knowledgeable in their respective roles.  All staff members had completed the required training and certifications per the licensing regulations. 

Resident Care and Services:  Residents' care plans were reviewed and found to be up-to-date.  Medication administration was observed to be by the facility's policies and procedures. Recreational activities and social engagement opportunities were available to residents regularly.

Continued on 809C
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: KP DISABILITY SERVICE 2
FACILITY NUMBER: 374603835
VISIT DATE: 02/26/2024
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Health and Safety:  Regular health assessments and monitoring of residents' well-being were conducted by qualified healthcare professionals.  Infection control measures were in place and followed by staff members. The facility had established protocols for emergencies and evacuation plans were readily available.

Overall, the facility was found to comply with the licensing regulations.  An exit interview was conducted and a copy of this report along with the Licensee Rights (LIC 9058) was provided to Kim Pollard, Administrator.  Her signature on this form confirms receipt of the documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Renita Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
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