Community Care Licensing

SUPERVISOR'S NAME: Jodean Hall TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Connie Goldie TELEPHONE: (916) 263-2000 LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Document Has Been Signed on 10/10/2024 05:42 PM - It Cannot Be Edited

FACILITY NAME: KAIR IN HOME SOCIAL SERVICES, INC	FACILITY NUMBER: 397005971
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

ILS

88270(a)(5)

(a) In addition to California Code of Regulations, Title 22, Section 88070, the following information regarding a child shall be obtained and maintained in the child’s case record by a foster family agency: (5) The original signed form LIC 613B: Personal Rights—Children’s Residential Facilities or an equivalent form. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review], the licensee did not comply with the section cited above in 1 out of 8 children did not have a personal rights form in file and two of 8 children did not sign their personal rights document which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2024
	Plan of Correction
1 2 3 4	Administrator will train on expectation of personal rights form to be signed and placed in child's record as per regulation to be in compliance. Submit proof or training to staff along with C3, C4 and C7's signatures to CCL by POC due date.

Type B

Section Cited

ILS

88270.1(b)(2)(J)

(b) A foster family agency shall maintain a separate, complete, and current record in the administrative office or suboffice for each nonminor dependent placed with the foster family agency. (2) The following information and related documents shall be included in a nonminor dependent’s records: (J) Documentation of all mental health services received by a nonminor, to include the services received, name of the mental health entity, and dates the services were provided. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 1 Non-minor dependents records which did not list mental health entity and dates of service which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2024
	Plan of Correction
1 2 3 4	Administrator will create a form for Non-Minor dependents to list mental health entity and dates of service to be placed into each record to bring facility into compliance. Administrator will submit a copy of form to CCL by POC due date.

SUPERVISOR'S NAME: Jodean Hall TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Connie Goldie TELEPHONE: (916) 263-2000 LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Document Has Been Signed on 10/10/2024 05:42 PM - It Cannot Be Edited

FACILITY NAME: KAIR IN HOME SOCIAL SERVICES, INC	FACILITY NUMBER: 397005971
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

ILS

88370(b)(1)(A)

(b)(1) A foster family agency shall document each case management visit to the home of a Resource Family, pursuant to subsection (a)(1). Documentation of the case management visit shall have the following: (A) The date and time of the visit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 8 out of 8 children's records were missing date and/or time of case management visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2024
	Plan of Correction
1 2 3 4	Administrator will train social workers to add date and time of visit to each progress note. Administrator will provide proof of training signed by attendees to CCL by POC due date

Type B

Section Cited

ILS

88710.1(b)(2)

(b) A foster family agency shall ensure that the capacity be no more than the total number of children and nonminor dependents that the ISFC Resource Family can properly care for as determined by the foster family agency, and meets the requirements the below: (2) No more than three children or nonminor dependents may be placed with an ISFC Resource Family. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 6 Intensive Services Foster Children resource family homes as five children are placed in a home with two ISFC youth which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2024
	Plan of Correction
1 2 3 4	Administrator will move two youth placed in resource family home to comply with regulation by POC due date. Administrator will send the transfer placement documentation to CCL as proof that agency is in compliance.

SUPERVISOR'S NAME: Jodean Hall TELEPHONE: (916) 263-4711 LICENSING EVALUATOR NAME: Connie Goldie TELEPHONE: (916) 263-2000 LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024