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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530306
Report Date: 02/21/2025
Date Signed: 02/21/2025 11:53:39 AM

Document Has Been Signed on 02/21/2025 11:53 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KANAK CARE HOMEFACILITY NUMBER:
365530306
ADMINISTRATOR/
DIRECTOR:		LUMBRIS, CARMELOFACILITY TYPE:
740
ADDRESS:3275 S NEWTON AVETELEPHONE:
(661) 549-3279
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 6CENSUS: 0DATE:
02/21/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Alka RaniTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Paola Guerrero conducted an announced pre-licensing visit to facility. LPA met with Facility Licensee Alka Rani. The pending application is for a Residential Care Facility. There are currently no Residents in care. The Licensee accompanied LPA on a tour of the inside and outside of the facility. The home is a five (5) bedroom, three (3) bathroom home with a living room, dining room, kitchen, and attached garage. The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor and outdoor passageways are free of obstruction. There are no pools, bodies of water, firearms, or ammunition. All bedrooms are furnished with a bed, nightstand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, shower and tubs are in good repair and have non-skid mats. LPA measured and observed the water temperatures in the bathrooms to be at 115.9 degrees F. LPA observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer are maintained at appropriate temperatures. All appliances are clean and operating properly. Dishes, glasses, and utensils were in good condition. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use. LPA observed fully charged fire extinguisher present in the facility. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area (medication closet) where medications will be stored and locked. The facility had a designated area where staff and resident records will be stored. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There is adequate seating in the common areas. Facility had a supply of activities for the residents.

Pre-licensing inspection is complete, and no corrections are needed to be made. The Comp III presentation was completed during today's visit.

An exit interview was conducted, and a copy of this report was provided to Facility Licensee Alka Rani.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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