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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601207
Report Date: 06/11/2022
Date Signed: 06/11/2022 12:23:30 PM

Document Has Been Signed on 06/11/2022 12:23 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KINGSLEY HOME CAREFACILITY NUMBER:
198601207
ADMINISTRATOR:ROBERT WILLIAMS IIFACILITY TYPE:
735
ADDRESS:635 E KINGSLEY AVETELEPHONE:
(909) 524-9446
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 3DATE:
06/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Robert WilliamsTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Robert Williams and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply. The facility cares for adults with intellectual disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4E facility.

All client bedrooms were toured. All bedrooms are private and have beds, required linen, dresser, light, and sufficient closet space. Both client bathrooms were toured and the hot water was 107.5 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. All chemicals are locked in the laundry room and garage. The kitchen was inspected. There is sufficient perishable and non-perishable food. There is additional food in the garage. All the appliances are clean and are operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. Facility currently has at least a 30-day supply of PPEs. There are cameras inside the facility in common areas. There is no screening station at the entrance of the facility. Staff document client temperatures and symptoms daily as required.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during. There was a Technical Assistance letter provided. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2022
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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