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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191801893
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:32:49 PM

Document Has Been Signed on 10/11/2022 03:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KINGSLEY GROUP HOME IIFACILITY NUMBER:
191801893
ADMINISTRATOR:LORCA, ANITAFACILITY TYPE:
735
ADDRESS:3279 LARGA AVE.TELEPHONE:
(323) 664-2049
CITY:LOS ANGELESSTATE: CAZIP CODE:
90039
CAPACITY: 10CENSUS: 6DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Valentin Dizon - StaffTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required 1 Year visit to this facility. LPA met with staff Valentin Dizon who called the administrator and designated him to sign the report as she is indisposed. LPA explained the reason for the visit. Five (5) of the residents were at the Day Program during visit.

A tour of the physical plant was conducted at 9:18 AM and the following was noted:

The side main door is the only entrance being utilized at the facility. There is a sign on the side door that everyone entering at the facility must be screened. Screening area is located about ten (10) feet upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask.

The facility had submitted approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility.

The facility is a two - storey home and has two (2) staff rooms, five (5) client rooms and four (4) bathrooms. Smoke detectors and Carbon Monoxide detectors were tested and observed to be functioning properly. Fire extinguishers were fully charged and last serviced in 03/03/22. There is also a pull fire alarm system installed at the facility.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KINGSLEY GROUP HOME II
FACILITY NUMBER: 191801893
VISIT DATE: 10/11/2022
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(continued from LIC 809)

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food. Sharp objects are stored in a locked tool box in a bottom drawer to the left of the oven.

Bedrooms: The resident bedrooms were properly furnished and had adequate lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured between 114.2°F to 114.5°F.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair. Laundry area is located in the common area adjacent to the kitchen. The thermostat temperature was set at 75.0°F.

Medication: LPA observed medication in cabinet in the office area across from the kitchen. LPA observed the cabinet to be locked. There is a complete first aid kit stored in the medication cabinet.

Surrounding Grounds (Outdoors): The facility is fenced with self-closing latch. There were shaded patio areas with proper furniture for outdoor use in the front and the side of the facility. The garage is being used as a storage for old furniture and medical and frozen food supplies. There is no body of water on the premises.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, no deficiencies were observed/cited.

Exit Interview conducted and copy of report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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