Kinah Mae Home RPV

Type of visit: Required - 1 Year

On 06/02/26 Licensing Program Analyst (LPA) Mario Leon created an amendment of this file, which is to change this visit's type from Post Licensing to REQUIRED - 1 YEAR. On 01/14/26 Licensing Program Analyst (LPA) Mario Leon conducted a required annual visit at the facility. Upon entrance, LPA was met by staff one, Renette De La Cruz - Licensee (S1) and the purpose of the visit was explained. The facility is a single-story home located in a residential neighborhood, which consists of the following: four (4) bedrooms, two “half-bath” (2) bathrooms, one (1) kitchen, (1) dining room, one (1) living room, with an attached garage, and is located within a residential neighborhood. Facility maintains all required posting throughout the facility. LPA reviewed both resident files and found that they contained all required documents. LPA reviewed two (2) staff files and found they contained the required documents, and trainings. LPA reviewed their Liability Insurance. LPA reviewed the training logs for staff. The facility has a current census of three (3) residents (R1-R3). S1 and LPA toured the facility, inside and out. MEDICATIONS: There is a locked centralized storage area for client medications. PHYSICAL PLANT: Facility is clean, sanitary, and in good repair. Protective devices are in place to include fire prevention and mitigation and all are operational. Indoor and outdoor passageways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. There is one (1) pool, located in the back yard with a locked 5ft-high fence surrounding the water, making the water inaccessible to residents in care. There are locked storage areas for poisons, pool chemicals and sharps. All window screens are clean and in good repair. Facility maintains a comfortable temperature at 77.5 degrees F. The facility has central air. Inclines, ramps, open porches, and areas of potential hazard are well-lit and adequately equipped for elderly residents. Nine (9) smoke detectors are hard wired and operate properly. Two (2) Carbon monoxide detectors operate properly. S1 shut off the facility power source to indicate emergency lighting as operational. Report continues, please see LIC809-C. All kitchen, food storage, and preparation areas are clean and food items are labeled by date of purchase by S1. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. Both have been observed as locked. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Facility Visiting Policy is posted within the Admissions Agreement and nearby other mandated reporting poster(s). Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is a shared outdoor activity space with shaded areas and are furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies which include newspapers, magazines, and a variety of reading material as well as a variety of different types of “stress ball” present. MISCELLANEOUS There are first-aid supplies which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies are present, which includes flashlights with batteries. Vehicles used to transport clients are in safe operating condition. During today's inspection, LPA observed four (4) staff present. Upon review of Personnel Summary, there are only two (2) staff associated. When asked about the additional staff, S1 informed LPA that the two (2) additional staff's association has been mailed to Sacramento during the prior week. LPA did not cite, as the two (2) staff's paperwork are also being held at the facility. LPA created a technical violation, please see LIC9102TV. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Renette De La Cruz and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 01/15/2025 The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was held, in-person, with staff one Renette De La Cruz, Administrator (S1). On 07/31/2024 an application was submitted to CCLD, for an initial license for a Residential Care Facility for the Elderly to serve Elderly adults from ages 60 and above. Requested capacity is for six (6) clients of which five (5) may be non-ambulatory and one (1) client who is bedridden. The facility has a hospice waiver for six (6) clients in care. The facility is a single-story home which includes four (4) bedrooms, two “half-bath” (2) bathrooms, one (1) kitchen, (1) dining room, one (1) living room, with an attached garage, and is located within a residential neighborhood. CCLD staff conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pre-Licensing Checklist and Component III Orientation with S1. MEDICATIONS There is a locked centralized storage area for client medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place to include fire prevention and mitigation and all are operational. Indoor and outdoor passageways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. There is one (1) pool, located in the back yard with a locked 5ft-high fence surrounding the water, making the water inaccessible to residents in care. There are locked storage areas for poisons, pool chemicals and sharps. All window screens are clean and in good repair. Facility maintains a comfortable temperature at 77.5 degrees F. The facility has central air. Inclines, ramps, open porches, and areas of potential hazard are well-lit and adequately equipped for elderly residents. Nine (9) smoke detectors are hard wired and operate properly. Two (2) Carbon monoxide detectors operate properly. S1 shut off the facility power source to indicate emergency lighting as operational. Report continues, see LIC809-C BEDROOMS Halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings are not being used as client bedrooms. Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath or toilet and each room’s overhead light and fan are in working condition. There is a bed for each client with a bedspring, mattress, waterproof cover, fitted sheets, flat sheets, two (2) blankets and pillow covers which are clean and in good repair. Mattresses and pillows are flame-retardant. Each resident has their own chest of drawers in addition to closet space that includes at least two (2) drawers and eight (8) cubic feet of dresser space per client. Two (2) private use bedrooms host one (1) chair, (1) bedside table and one (1) reading lamp. Two (2) shared bedrooms each include two (2) chairs, one (1) bedside table and one (1) reading lamp. BATHROOMS Bathroom #1 is for client use and has one (1) toilet, two (2) washbasins and one (1) shower and the water temperature was measured at 115.1ºF. Bathroom #2 has one (1) toilet, one (1) washbasin and one (1) shower available for client, family, and personnel use and the water temperature was measured at 113.5 ºF. All bathrooms are located near client bedrooms, were observed to be without mold and comply within title 22 regulations. There are nightlights throughout the facility and emergency lighting was observed in operation. SUPPLIES There are client personal hygiene supplies which included feminine napkins, soap, shampoo, toothbrush, toothpaste, and additional paper supplies and Personal Protective Equipment (PPE). There is a sufficient supply of clean linens to permit weekly changing, or more, of client’s bedding, located within each room’s closet which include top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers and CCLD also observed ample bath towels, hand towels, and washcloths which are located in the hallway dresser. FOOD SERVICE The Dining room is near the kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer has been marked as 0ºF on the Daily Temperature Report for refrigerator and freezer. Refrigerator temperature log shows an average of 37 ºF and a Daily Temperature Report is stored nearby. A seven (7) day supply of non-perishable food is present. There are adequate tableware, tables, dishes, and utensils while hosting six (6) clients in care. There are equipment for the storage, preparation, and service of food to clients in care. All equipment, dishes, and utensils are clean and well maintained. Report continues, see LIC809-C. All kitchen, food storage, and preparation areas are clean and food items are labeled by date of purchase by S1. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. Both have been observed as locked. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Facility Visiting Policy is posted within the Admissions Agreement and nearby other mandated reporting poster(s). Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is a shared outdoor activity space with shaded areas and are furnished for outdoor use. There is at least one common room available to clients for visitors. There are activity supplies which include newspapers, magazines, and a variety of reading material as well as a variety of different types of “stress ball” present. MISCELLANEOUS There are first-aid supplies which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies are present, which includes flashlights with batteries. Vehicles used to transport clients are in safe operating condition. PRE-LICENSING CHECKLIST has been completed by licensee via Central Applications Bureau (CAB) and was reviewed by CCLD staff. COMPONENT III was provided via PowerPoint presentation; information was provided about how to operate the facility within substantial compliance. During the pre-licensing inspection, CCLD observed the liability insurance total aggregate at two-million (2,000,000) dollars (2M) which is below standards noted under Health and Safety Code (HSC) 1569.605. HSC1569.605 requests a facility to hold a total aggregate at three-million (3,000,000) dollars (3M). S1 and CCLD contacted witness one (W1), insurance agent. W1 confirmed that the total aggregate will be increased to 3M dollars prior to residents moving into this facility. CCLD marked this as a technical violation, as CCLD observed and received a verbal confirmation to increase the total aggregate to 3M prior to residents moving into this facility. Please see LIC9102-TV. Report continues, please see LIC809-C. There have been zero (0) deficiencies cited during today's visit. An exit interview was conducted, and a hard copy of this report has been provided to Renette De La Cruz (S1). Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.the state’s words, verbatim · CDSS document, Jan 15, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: CRUZ, RENETTE DE LA - Licensee/Administrator Interview Method: Telephone interview On 12/19/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 19, 2024