198601207-3-13-2026-28-AS-GCAO-DS65GU-20260313195717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601207
Report Date: 03/13/2026
Date Signed: 03/13/2026 07:57:57 PM

Document Has Been Signed on 03/13/2026 07:57 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	KINGSLEY HOME CARE		FACILITY NUMBER:	198601207
ADMINISTRATOR/ DIRECTOR:	ROBERT WILLIAMS II		FACILITY TYPE:	735
ADDRESS:	635 E KINGSLEY AVE		TELEPHONE:	(909) 524-9446
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY: 6		CENSUS: 4	DATE:	03/13/2026
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Robert Williams, Admin.		TIME VISIT/ INSPECTION COMPLETED:	10:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced Case Management Plan of Correction (POC) visit to address deficiencies related to the facility’s failure to correct previously cited deficiencies. LPA was greeted by Robert Williams and explained the purpose of the visit.

Case Management POC visit was conducted to follow up on deficiencies cited during the facility’s unannounced Annual Inspection on March 10, 2026, for which POC’s were due by March 11, 2026.

The following deficiencies were cited on March 10, 2026:

CCR 80087 (a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

POC- Licensee shall ensure the facility is maintained in a clean, safe, and sanitary condition at all times. Licensee shall clean the dining area, dining furniture, and restrooms to remove visible dirt and grime. Licensee shall also repair or replace the broken kitchen drawers to ensure they are in good repair and safe for use by POC due date.

During today's visit, LPA observed the facility to be cleaner, safer, and in sanitary condition. The Administrator and LPA discussed a plan moving forward to ensure the home is maintained in a clean and safe condition. Kitchen drawers are in the process of being repaired.- Deficiency Cleared

CCR 80087(g)

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

(continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE	FACILITY NUMBER: 198601207
	VISIT DATE: 03/13/2026

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POC- Licensee shall ensure that all chemicals and hazardous cleaning supplies are stored in locked cabinets or areas that are inaccessible to clients at all times by POC due date.

During today’s visit LPA observed all disinfectants will be placed in the detached garage that remains locked and chemicals are inaccessible to clients. -Deficiency Cleared

CCR 80088(e)(3)

(3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

POC- Licensee shall ensure that all restrooms in the facility are maintained in a clean and sanitary condition at all times. Licensee shall thoroughly clean and sanitize the restrooms to remove visible dirt and grime by POC due date.

During today's visit, LPA observed staff in the process of cleaning the restrooms, which appeared cleaner compared to the initial visit conducted on 03/10/2026. LPA and the Administrator discussed a plan moving forward to ensure the restrooms are maintained in a clean and sanitary condition.-Deficiency Cleared

CCR 85076(d)(1)

(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

POC- Licensee shall ensure the facility maintains a sufficient supply of at least two (2) days of perishable food for residents at all times.

During today's visit, LPA observed that the facility did not have at least two (2) days of perishable food on hand. Per the Administrator, residents do not prefer eating fruits and vegetables; however, the Administrator stated that staff would be going out to purchase additional food items today.-Deficiency not cleared- civil penalties will be assessed during today's visit.

During today’s visit, LPA reviewed the status of the previously cited deficiencies. LPA observed that some deficiencies have been corrected, while one remained uncorrected as of today’s visit. Civil penalties were issued for the deficiency that was not corrected by the required POC due date.

An exit interview was conducted. Copies of the report and Appeal Rights were provided to Administrator Robert Williams.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026

LIC809 (FAS) - (06/04)

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