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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005971
Report Date: 03/14/2022
Date Signed: 03/16/2022 10:58:45 AM

Document Has Been Signed on 03/16/2022 10:58 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
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833
FACILITY NAME:KAIR IN HOME SOCIAL SERVICES, INCFACILITY NUMBER:
397005971
ADMINISTRATOR:MONIQUE PERSONFACILITY TYPE:
430
ADDRESS:2105 W MARCH LANE, STE 2TELEPHONE:
(209) 954-0614
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 29CENSUS: DATE:
03/14/2022
TYPE OF VISIT:Required - 2 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gurmeet Raj Singh, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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On 3/23/22 at 9:00am, Licensing Program Analyst (LPA) Stephanie Lor, LPA Jacqueline Carmona, and LPM Rosa Rodriguez made an unannounced visit at the agency for the purpose of completing a required 2 Year Annual Inspection. During the inspection, the LPAs and LPM met with the Administrator and CEO

LPA conducted a walk-through of the facility inside and out. There are 7 offices, 1 kitchen, and required posters are posted. LPA reviewed 3 family files, 6 staff files, and 6 client files during the inspection.

Prior to the inspection, LPA reviewed: annual fees, administrator certificate for Monique Person, accreditation expiration date of 9/30/23, waivers and exception (5 individuals on file), personnel roster (154 associated),

LPA inspected the following

  • Physical Plant: A TV was issued due to a box of detergent and alcohol accessible to client in the front of the entrance office. A 2nd TV was issued for the water temperature of 140F, but due to no children present on site, no citation was given. A TA was issued for no lid on the trash can located in the kitchen. A Type B violation was cited due to first aid missing a manual, scissor, tweezer, and adhesive tape.
  • Operation: All requirements met. No citation cited for this section of the domain.
  • Disaster Preparedness: All requirements met. No citation cited for this section of the domain.
  • Staffing: A type B was cited due to no training certificates located in 6 out of the 6 staff's files.
  • Client records: A Type B citation was issued due to 6 out of 6 files with incomplete emergency information. A TA was given for no termination/discharge policy in the files. Staff provided the forms during this inspection.
(See cont page)
SUPERVISORS NAME: Rosa Rodriguez
LICENSING EVALUATOR NAME: Stephanie Lor
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833
FACILITY NAME: KAIR IN HOME SOCIAL SERVICES, INC
FACILITY NUMBER: 397005971
VISIT DATE: 03/14/2022
NARRATIVE
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  • RF Record: All requirements met. No citations given for this section of the domain.
  • RF Family Portability Records: All requirements met. No citations given for this section of the domain.
  • ISFC Resource Family Records: All requirements met. No citations given for this section of the domain.
  • Certified Family Home Records: All requirements met. No citations given for this section of the domain.
  • Core/Therapeutic Services: All requirements met. No citations given for this section of the domain.
  • Clients with Special Health Care Needs: All requirements met. No citations given for this section of the domain.

An exit interview was conducted with the Administrator. A copy of the report will be email to the facility.



SUPERVISORS NAME: Rosa Rodriguez
LICENSING EVALUATOR NAME: Stephanie Lor
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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Document Has Been Signed on 03/16/2022 10:58 AM - It Cannot Be Edited


Created By: Stephanie Lor On 03/14/2022 at 04:25 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
, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME: KAIR IN HOME SOCIAL SERVICES, INC
FACILITY NUMBER: 397005971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(g)(1)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. (1) The supplies shall include at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Lor's observation, the licensee did not comply with the section cited above in the domain section phyical plant which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2022
Plan of Correction
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The facility will purchase the missing items a manual, scissor, tweezer, and adhesive tape. A picture will be emailed to LPA Lor via email stephanie.lor@dss.ca.gov
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA Lor reviewed the staff files, the licensee did not comply with the section cited above in 6 out of 6 files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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The facility will complete the appropirate training, provide a copy in the staff's files and email a copy to LPA Lor via email at stephanie.lor@dss.ca.gov by 4/14/21.
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:Rosa Rodriguez
LICENSING EVALUATOR NAME:Stephanie Lor
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/16/2022 10:58 AM - It Cannot Be Edited


Created By: Stephanie Lor On 03/14/2022 at 04:25 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
, 2525 NATOMAS PARK DR., STE 260
SACRAMENTO, CA 95833

FACILITY NAME: KAIR IN HOME SOCIAL SERVICES, INC
FACILITY NUMBER: 397005971

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
88070(a)(1)(G)
Children's Case Records
(1) The following information regarding the child shall be obtained and maintained by the foster family agency: (G) The list of persons who should or should not be allowed to visit and any limitations on visitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA Lor reviewed the client files, the licensee did not comply with the section cited above in 6 out of 6 client files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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The facility will complete the Emergency Information form and provide a copy to LPA Lor via email at stephanie.lor@dss.ca.gov by 3/25/22. A copy of the file review during the inspection will be email to the facility (see LIC858 and 811).
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:Rosa Rodriguez
LICENSING EVALUATOR NAME:Stephanie Lor
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


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