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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606887
Report Date: 09/04/2025
Date Signed: 09/04/2025 02:00:21 PM

Document Has Been Signed on 09/04/2025 02:00 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KATHLEEN CARE HOMEFACILITY NUMBER:
197606887
ADMINISTRATOR/
DIRECTOR:		ORLANDO J. VALERAFACILITY TYPE:
740
ADDRESS:1531 KIOWA CREST DRIVETELEPHONE:
(909) 860-8288
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 5DATE:
09/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Orlando Valera - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Victoria Valera and Edmar Limoico, Care Staff and explained the purpose of the visit. Shortly after, Administrator Orlando Valera arrived and assisted LPA with the inspection. The facility is approved to serve elderly clients. Fire cleared for (6) non ambulatory clients. Hospice waiver approved for (2) clients. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.


Operational Requirements: A fire clearance is in place. Fire Drill is conducted monthly and the last drill was conducted on 08/05/2025. Facility has working signal systems in exit points.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (1) staff bedroom, (1) office/bedroom, (2) bathrooms, living room with covered fireplace, kitchen, dining area, laundry area in the attached garage and backyard with shaded patio area. There are currently (5) residents, 60 years and older residing in the facility, no one is under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed cameras in the common areas with no audio. Backyard was inspected and has a shaded area and sitting area. There are (2) fire extinguishers in the facility which was purchased on 12/30/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. 10:50am, readings were 114.4 deg. F in bathroom #1 and 113.9 deg F in bathroom #2. *****REPORT CONTINUED ON LIC809-C*****
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KATHLEEN CARE HOME
FACILITY NUMBER: 197606887
VISIT DATE: 09/04/2025
NARRATIVE
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Staffing: A total of (8) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.
Personnel Records-Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator has completed the required Administrator courses and submitted the certification renewal. Administrator's certificate valid through 08/21/2026.
Resident Rights-Information: Resident personal rights are posted. Visiting policy is posted at a location that is visible and accessible to residents and families. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. The facility provides sufficient space to accommodate both indoor and outdoor activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Pesticides and cleaning supplies are kept away from the food preparation areas.
Incidental Medical Services: All (5) residents' medications were reviewed during the visit.Resident #2 (R2) is taking nonprescription PRN without a written order from a physician and not on the medication list. Resident #1 (R1) has a written order from the Physician for PRN medication, but the label on the PRN medication being administered is incorrect. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications were stored in the office cabinet and inaccessible to residents. First-aid supplies along with a manual are maintained in the facility.
Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records. Staff failed to sign the Medication Administration Record (MAR) on the correct time and date (8am/Sep. 4, 2025) for one of the resident (R2).
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis. Last fire drill was conducted on 08/05/2025.
Residents with SHN: None of the residents is under hospice care. Physician orders for use of half bed rails were reviewed in (5) residents files. (1) out of (5) residents did not have a bed rail physician's order on file.

Deficiencies cited, Technical Violation issued. Exit interview and a copy of this report along with the appeal rights was provided to the Administrator, Orlando Valera.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/04/2025 02:00 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/04/2025 at 01:19 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KATHLEEN CARE HOME
FACILITY NUMBER: 197606887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that Resident #1 (R1) has a written order from the Physician for PRN medication (Calcium Carbonate-Vit D3), but the label on the PRN medication being administered is incorrect. Resident #2 (R2) is taking nonprescription PRN (CBD + THC Chill chews) without a written order from a physician and not on the medication list which poses/posed an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 09/05/2025
Plan of Correction
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Administrator shall ensure that all residents have current medication list from their physicians. Administrator will send R1's doctor order for the PRN and proof of the correct PRN medication for R2 to LPA/CCL by POC due date.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/04/2025 02:00 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/04/2025 at 01:19 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KATHLEEN CARE HOME
FACILITY NUMBER: 197606887

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that Staff failed to sign the Medication Administration Record (MAR) at the proper time and date (8am/Sep. 4, 2025) for R2 which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 09/12/2025
Plan of Correction
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Administrator shall provide in-service training to all staff on how to properly document the Medication Administration Record (MAR), as well as develop a policy requiring that (2) people verify medication records. Administrator to send a copy of the training log, along with the topics covered, and a sign-in sheet of staff who participated to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in that (1) out of (5) residents have half bed rails in their beds and there was no bed rail physician's order on file which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 09/12/2025
Plan of Correction
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Administrator will submit a copy of the physician's order to use half bed rail for R2 and photos to LPA/CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2025


LIC809 (FAS) - (06/04)
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