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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601207
Report Date: 04/03/2025
Date Signed: 04/03/2025 10:17:10 AM

Document Has Been Signed on 04/03/2025 10:17 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/
DIRECTOR:		ROBERT WILLIAMS IIFACILITY TYPE:
735
ADDRESS:635 E KINGSLEY AVETELEPHONE:
(909) 524-9446
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 4DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Robert WilliamsTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Robert Williams (Administrator). LPA explained the purpose of today's visit.

This facility consists of a single-story home with (3) bedrooms, (2) bathrooms (1 located inside room #1), kitchen, dining area, living room and detached garage. This facility is approved for (6) ambulatory clients. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

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



Infection Control: Facility has an Infection Control plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms tested and operable. Carbon monoxide detector tested and operable (located in living room). Fire extinguishers were observed in the kitchen and hallway and appeared to be full. Last fire drill was conducted 03/27/25. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Passageways were free of obstruction.

Staffing: Staff files were not at this facility during this visit. Deficiency cited.

Refer to LIC 809C for the continuation of this report.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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Document Has Been Signed on 04/03/2025 10:17 AM - It Cannot Be Edited


Created By: Elizabeth Irra On 04/03/2025 at 09:32 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: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070(a) Client Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This standard is not met as evidence by: During today's visit, client files for C-3 and C-4 were not on-site.
Deficient Practice Statement
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Based on administrator interview, the licensee did not comply with the section cited above in [2] out of [4] client files were not on-site which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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Administrator to submit a written statement as to how the files will be kept on-site (in this facility at all times) by POC due date.
Type B
Section Cited
CCR
80066(e)
80066(e) Personnel Records: (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This standard is not met as evidence by: During today's visit, personnel files were not on-site.
Deficient Practice Statement
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Based on administrator interview, the licensee did not comply with the section cited above as personnel files were not on-site which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
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Administrator to submit a written statement as to how the personnel files will be kept on-site (in this facility at all times) by 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.
Tony Vasallo
NAME OF LICENSING PROGRAM MANAGER:
Elizabeth Irra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207
VISIT DATE: 04/03/2025
NARRATIVE
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Personnel Records-Training: Staff files were not at this facility during this visit. Deficiency cited.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) and Client #2 (C-2). For C-1 and C-2, the following was observed: Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights. Client files for Client #3 (C-3) and Client #4 (C-4) were not at this facility during this visit. Deficiency cited.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply was observed inside the garage. The food is properly stored in the refrigerators. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked near the kitchen. Medications are administered as prescribed by the Physician. C-1 and C-2 are the only clients taking medication.

Incidental Medical Services: Per Administrator, there are (0) clients with a restrictive health plan, (0) client utilizing postural supports and (0) clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place. Last fire drill was conducted on 03/27/25.

Deficiencies cited and civil penalties applied (repeat violations within a 12-month period). Exit interview, appeals rights and a copy of this report was provided to Robert Williams.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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