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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608102
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:44:51 PM

Document Has Been Signed on 03/14/2024 02:44 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KIND HEART HOME CARE IIIFACILITY NUMBER:
197608102
ADMINISTRATOR:COTY LUBIANO-CABRALFACILITY TYPE:
740
ADDRESS:2033 W. 231ST STREETTELEPHONE:
(310) 782-5045
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 5DATE:
03/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Christian EspinoTIME COMPLETED:
03:00 PM
NARRATIVE
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On 03/14/2024 at 1:06 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with Staff Jocelyn Letigio. Assistant Administrator Christian Espino joined us later.

LPA interviewed two staff members and two residents.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. As of 01/31/24, the Fire Inspector is awaiting for ADT to provide a report on the facilities' monitoring system. In addition, a violation regarding criminal record transfer clearance warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421BG. Staff #2 was working on-site and was not associated to the facility.

An exit interview was conducted, Plans of Corrections were developed and reviewed. A copy of this report and appeal rights were discussed and left with the Administrator Christian Espino.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 02:44 PM - It Cannot Be Edited


Created By: Regina Cloyd On 03/14/2024 at 02:16 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KIND HEART HOME CARE III
FACILITY NUMBER: 197608102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses/posed a potential safety risk to persons in care. The Fire Inspector is waiting for a report from ADT concerning the facility's monitoring system.
POC Due Date: 03/29/2024
Plan of Correction
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The Licensee will provide proof of correction to regina.cloyd@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for Staff #2 which posed a potential safety risk to persons in care. LPA Cloyd did not find S2 associated to the facility in Guardian.
POC Due Date: 03/15/2024
Plan of Correction
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The Licensee will provide proof of correction to regina.cloyd@dss.ca.gov by the 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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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