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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603835
Report Date: 06/08/2022
Date Signed: 06/08/2022 05:36:59 PM

Document Has Been Signed on 06/08/2022 05:36 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
CCLD Regional Office, 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:
06/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Administrator Kim PollardTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management Visit. LPA was allowed entry and met with Administrator Kim Pollard. LPA identified herself and discussed the purpose of the visit.

Today's visit is in response to the self-reported incident which occurred on 06/04//2022 regarding an AWOL of Client 1 (C1 - see LIC811 Confidential Names List).

LPA conducted a wellness check at the facility by touring the facility, observing that clients in care appeared appropriate for the facility, interviewing staff, and collecting client records.

According to the Special Incident Report (LIC 624), C1 went AWOL on Saturday 06/04/2022 during the afternoon. Licensee did not follow the Absentee Notification Plan as recorded in the Facility Plan of Operations which states that staff will contact the police department within two hours of a client being missing. Interview with staff confirmed that C1 did not return to the facility at teh designated curfew hour on 06/04/2022. Staff interview confirmed that police department was not contacted. C1 did not return to the facility until Sunday 06/05/2022 at 8:19 p.m.

Based on facility records and interviews, deficiencies were cited during this visit of Health and Safety Code 1507.15. An 809-D page is attached to this Facility Visit Report.

LPA amended 809D page on site during the visit to include signatures. An exit interview was conducted with the Administrator Kim Pollard. A copy of this report and appeal rights (LIC9056 01/16), were provided via hardcopy.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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Document Has Been Signed on 06/09/2022 08:45 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/08/2022 05:33 PM


Created By: Kayla Hilario On 06/08/2022 at 05:14 PM
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: KP DISABILITY SERVICE 2
FACILITY NUMBER: 374603835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2022
Section Cited
HSC
1507.15

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1507.15 Absentee Notification Plan for Residents and Participants: Every community care facility...shall, for the purpose of addressing issues that arise when an adult resident is missing...develop and comply with an absentee notification plan for each resident. This requirement was not met as evidenced by:
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Licensee shall read the regulation in its entirety, train staff on this regulation, submit a statement of understanding and training log to CCL by the POC due date of 06/09/2022.
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Based on facility documents and interview with staff, facility did not comply with the Absentee Notification Plan for 1 of 6 clients by not contacting the police department as indicated in the facility Plan of Operations, which causes an immediate health and safety risk 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.
SUPERVISOR'S NAME:John Rante
LICENSING EVALUATOR NAME:Kayla Hilario
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022


LIC809 (FAS) - (06/04)
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