502701324-2-15-2024-27-AS-RCAL-D2H3JN-20240215171748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701324
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:17:57 PM

Document Has Been Signed on 02/15/2024 05:17 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	KIMBALL HILL CARE HOME LLC		FACILITY NUMBER:	502701324
ADMINISTRATOR:	KAUR, TASWARDEEP		FACILITY TYPE:	735
ADDRESS:	3129 KIMBALL HILL DR.		TELEPHONE:	(209) 535-4952
CITY:	CERES	STATE: CA	ZIP CODE:	95307
CAPACITY: 4		CENSUS: 0	DATE:	02/15/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Licensee, Ramandeep (Rammy) Kaur		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/15/24 at approximately 3:00 PM Licensing Program Analyst (LPA) Renee Campbell arrived for a second announced visit to complete the prelicensing requirements. LPA was met by applicant Rammy Kaur. This Applicant was seeking licensure for a 4-bed ARF. An ambulatory fire clearance was granted for this single one floor building for (4) residents in a non-sprinkled house with a backyard building for storage only. The facility will have 24/7 staffing and care. LPA Campbell and Licensee Kaur conducted a tour of this facility. The kitchen area was observed. Cabinets and drawers were reviewed. Knives were properly stored and locked in a cabinet made inaccessible to residents. Below it, the P and I lockbox was also observed in another locked drawer. The refrigerator temperature was measured at 35 degrees Fahrenheit which is below the required maximum of 45 degrees Fahrenheit. The freezer temperature was measured at 0 degrees Fahrenheit which is the same as the required minimum. Next to the refrigerator was a locked closet. LPA Campbell observed medication containers for each resident and a double lock safety cabinet for narcotics as needed. The fire extinguisher, located in the kitchen area, was observed to have been last inspected on 07/31/2023. A See Something Say Something poster was on the kitchen wall as well. The living room, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Resident bedrooms were toured. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Items observed in each bedroom included beds, chairs, lamps, drawers and closets. One bedroom had its own bathroom. Another bathroom as observed off the living room area and was suitable for use. Grab bars and non skid mats were observed to be present and able to meet the needs of the residents at this time.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KIMBALL HILL CARE HOME LLC	FACILITY NUMBER: 502701324
	VISIT DATE: 02/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Campbell observed a locked closet for chemical cleaning agents containing washing detergent. THe applicant has also prepared hygiene baskets for new residents that contained lotion, shampoo, body wash, conditioner, toothbrush, toothpaste and loofahs. Next to the chemical agent closet was the laundry room. The laundry machines and dryer were observed in the entrance to the garage and could be locked to prevent access by residents.. The garage area was toured. The applicant stated that the staff office would be in the garage. A table and printer on a long table was observed along with a file cabinet for employee and resident files, and space for non-perishable excess food storage.

Since the prior visit, the applicant has obtained a land line available to all residents and staff that is stationed on the kitchen island. Appropriate beds and linens have been provided for each room. There are now two single rooms with full size mattresses and one double room with two twin beds. Comp III has been completed. Containers have also been added for individual resident's needs.

A tour of the exterior grounds was conducted. In the backyard, LPA Campbell observed an empty shed for storage. Applicant Kaur nailed the opening of the shed shut for the safety of the residents.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited.
Exit interview held, copy of report given.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2