<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601207
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:36:26 AM

Document Has Been Signed on 05/09/2023 11:36 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
GREATER LA AC/SC, 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: 2DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Robert WilliamsTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Robert Williams/Facility Administrator and explained the purpose of today's visit.

This is a single story home with 3 bedroom, 2 bathrooms (1 located inside room #1), kitchen, dining area and living room. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. This facility has surveillance cameras outside the home and in the common areas inside the property. Cameras do not have audio.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies. Bathrooms have hand washing signs, soap and paper towels.

Operational Requirements: The fire clearance is approved for (6) ambulatory clients. Last Fire Drill was conducted 04/23/23. Last Earthquake Drill was conducted 04/15/23. Staff are adhering to operational requirements.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207
VISIT DATE: 05/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguishers is located above the medication cabinet and on hallway. They appear to be full. Carbon monoxide was located in the living room (tested and operable). Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured at: 113.0* in the hallway bathroom and 113.9* in the bathroom located inside room #1.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Robert Williams on file has an expiration date of 01/22/2022. However, Mr. Williams provided documentation pertaining to the Administrator Certificate renewal documents that were submitted to CCLD. Per Mr. Williams, he followed up and will be receiving the renewed Administrator Certificate. Robert Williams (ARF) HIV Certificate on file is dated 03/27/2009. Per Mr. Williams, was unaware this training required renewal (Citation will be issued). Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff #1 (S-1) through Staff #4 (S-4). Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #2 (C-2). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Per Facility Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside a cabinet). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

*** Refer to LIC 809 for the continuation of this report***
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
Page: 8 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207
VISIT DATE: 05/09/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Health Related Services The medications are centrally stored and in their original containers. Medications are bubbled packed and stored inside a locked closet. LPA reviewed medication for C-1 through C-2. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Facility Administrator, there are no clients with restricted health care conditions.

Disaster Preparedness: The facility does not have the Emergency Disaster Plan (LIC610D/9 pages) (Citation will be issued)

Deficiencies cited. Exit interview, appeals rights and a copy of this report was provided to Robert Williams

Note: LPA was experiencing technical difficulties during this visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 05/09/2023 11:36 AM - It Cannot Be Edited


Created By: Elizabeth Irra On 05/09/2023 at 10:36 AM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record view, the licensee did not comply with the section cited above as the facility did not have a complete disaster and mass casualty plan which poses/posed a potential health, safety or personal rights risk to persons in care. This standard is not met at evidence by: Facility does not have a complete Disaster and Mass Casualty Plan. LPA provided Administrator with guidance on how to retrieve the LIC 610D through the CDSS website.
POC Due Date: 05/23/2023
Plan of Correction
1
2
3
4
 This standard is not met at evidence by: Facility does not have a complete Disaster and Mass Casualty Plan. LPA provided Administrator with guidance on how to retrieve the LIC 610D through the CDSS website.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 05/09/2023 11:36 AM - It Cannot Be Edited


Created By: Elizabeth Irra On 05/09/2023 at 11:06 AM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and administrator confirmation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. HIV and TB training Certificate for Robert Williams (Administrator) was dated 03/27/2009. Per Administrator, he has not taken an updated training after 03/27/2009.
POC Due Date: 05/16/2023
Plan of Correction
1
2
3
4
Administrator to submit proof of HIV and TB training registration to LPA Irra by POC due date noted above.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 11 of 11