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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603957
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:05:25 PM

Document Has Been Signed on 02/14/2024 12:05 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
RIVERSIDE AC/SC, 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: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Elsa Monzon, Care ProviderTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Caregiver, Elsa Monzon and explained the purpose of the visit. A tour of the facility was conducted inside and out. At the time of visit, there were no clients home and no additional staff were available. LPA was informed the clients were currently attending day program. LPA conducted an interview with Caregiver, Elsa Monzon.

The facility is a five (5) bedroom three (3) bathroom two story home. The facility is licensed to serve six (6) developmentally disabled adults, ages 18 to 59, all of whom may be non-ambulatory.

During the tour the following was observed: Clients bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible to clients. Hot water was tested at 106 degrees Fahrenheit. Backyard area is free from obstructions.

Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional.

Care & Supervision: Facility has sufficient care staff employed.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KIMBALL RESIDENTIAL CARE HOME
FACILITY NUMBER: 374603957
VISIT DATE: 02/14/2024
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Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted monthly. The last drill was conducted on 1/5/2024.

Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed and contained required documents. IPP and Physician reports are current. LPA reviewed P&I receipts. P&I funds are kept separately from facility fund.

Medication Review: LPA reviewed medication and medication log. Client's medications are being dispensed according to physician's orders.

No deficiencies were observed during today's visit. A copy of this report was provided to Elsa Monzon, Care provider.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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