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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603957
Report Date: 02/14/2023
Date Signed: 02/14/2023 12:43:02 PM

Document Has Been Signed on 02/14/2023 12:43 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KIMBALL RESIDENTIAL CARE HOMEFACILITY NUMBER:
374603957
ADMINISTRATOR:JIMENEZ, BENCY G.FACILITY TYPE:
735
ADDRESS:710 KIMBALL STTELEPHONE:
(760) 738-7060
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 6DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:FACILITY MANAGER, LOURDES RODRIGUEZ.TIME COMPLETED:
12:52 PM
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On February 14, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection with emphasis on infection control. LPA Mixson met with Facility Manager introduced herself and stated the purpose of the visit.

Present in the facility were one resident and three staff. Five other residents were currently at the day program. At the time of this visit there are no positive cases of COVID-19 within the facility. All Residents and all Staff are fully vaccinated and Booster ed. Facility had sign-in sheet and check-in station for visitors and staff.

LPA Mixson observed residents have hand sanitizer available to them, and all restrooms were stocked with liquid soap and paper towels. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings.

The facility had a sufficient amount of liquid soap and paper towels in each of the restrooms and kitchen.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Facility Manager.

An exit interview was conducted and a copy of this report was provided to Facility Manager.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2023
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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