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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603957
Report Date: 02/12/2025
Date Signed: 02/12/2025 05:35:54 PM

Document Has Been Signed on 02/12/2025 05:35 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KIMBALL RESIDENTIAL CARE HOMEFACILITY NUMBER:
374603957
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, BENCY G.FACILITY TYPE:
735
ADDRESS:710 KIMBALL STTELEPHONE:
(760) 738-7060
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 6DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Leah Portillo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On 02/12/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted by Caregiver, Armida Benaires and explained the purpose of the visit. At the time of visit, there were (2) clients home and (2) staff were available. The facility is licensed to serve six (6) developmentally disabled adults, ages 18 to 59, all of whom may be non-ambulatory. The Administrator Bency Jimenez stated that he would try to make it to the facility within the hour as he had the Personal and Incidental funds with him. Administrator did not arrive by the time LPA concluded the visit therefore the funds were not reviewed during today's visit.

The facility is a two story structure consisting of five (5) client bedrooms, (2) bathrooms, backyard, kitchen, garage, and den on the first floor. On the second floor consists of (2) staff bedrooms and (1) bathroom. The client bedrooms and bathrooms were observed to be clean. The hot water temperature was tested and measured to be 116 degrees Farenheit to be within regulatory limits. The facility had an adequate food supply, as there was a 2 day supply of perishable and a 7 day supply of nonperishable food items. The facility activities to promote socialization.
The emergency disaster drills are being conducted on a monthly basis and that last fire drill was conducted on 1/12/25. There are no known guns or ammunition, or bodies of water on the premises. The chemicals and sharps were observed to locked and inaccessible to clients in care. The client files were reviewed and had the required documentation.
LPA conducted a staff file review and observed for Staff #1 (S1) to not have an employee file to review, nor to be associated to the facility. LPA cited immediate civil penalties of $500.00. LPA discussed the importance of having employee files available for review when requested by the department, and the potential consequences for not doing so. Based on today's inspection a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6) on the attached 809D.

An exit interview was conducted and a copy of this report, 809D, LIC421BG, and appeal rights were reviewed and provided to Leah Portillo, Caregiver.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 02/12/2025 05:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/12/2025 05:28 PM


Created By: Javina George On 02/12/2025 at 02:48 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KIMBALL RESIDENTIAL CARE HOME
FACILITY NUMBER: 374603957

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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S1 has an incomplete employee file, and no record found with the information provided, it was thought S1 didn't have criminal record clearance, after investigation with clearance ID, S1 has fingerprint clearance, but is not associated to the facility. Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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The Licensee agrees to have S1 associated to the facility. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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