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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601207
Report Date: 03/10/2026
Date Signed: 03/10/2026 05:07:13 PM

Document Has Been Signed on 03/10/2026 05:07 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 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:
03/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Robert Williams, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 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’s) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Administrator Robert Williams and explained the reason for the visit.

The facility is approved for (6) ambulatory clients ages 18 to 59. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

FACILITY TOUR AND OBSERVATIONS:

Physical Plant

The facility is a one-story residential home consisting of three (3) client bedrooms, kitchen, dining room, living room, two (2) bathrooms (one of which is a private restroom), laundry area, backyard patio, and a detached garage. Upon arrival, the LPA was informed that half of the facility had been without electricity for approximately one week. LPA observed the facility to be dirty and dusty throughout. The dining table area was observed to be dirty, and the dining room chairs were also observed to be dirty. The kitchen did not have electricity, and the refrigerator was non-functioning due to the lack of electricity. Kitchen drawers were observed to be broken or missing. Chemicals were observed under the kitchen sink unlocked and accessible to clients. Additional chemicals were observed in the laundry room. Client bedrooms were observed to be dirty. Some bedroom windows had broken window blinds, and windowsills throughout the home contained visible dirt accumulation. Restrooms were observed to be dirty with visible dirt and grime. Water temperature was measured at 119°F in bathroom (1) and 120°F in bathroom (2), which is within the required range of 105–120°F. Some smoke detectors were observed to be functioning; however, LPA also observed that some smoke detectors were missing in the facility. Charged fire extinguishers were observed in the facility. Facility exits were clear and no bodies of water were observed on the premises. The backyard contained shaded seating..

(Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
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)
Page: 2 of 13
Document Has Been Signed on 03/10/2026 05:07 PM - It Cannot Be Edited


Created By: Gabriela Castro On 03/10/2026 at 01:24 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation during the facility walkthrough, the licensee did not comply with the section cited above. LPA observed that some smoke detectors were missing or non-functioning in the facility, which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
Licensee shall ensure that all required smoke detectors are installed and in proper working condition throughout the facility by POC due date.
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the facility was not maintained in a clean and safe condition. LPA observed the dining area to be unclean, dining furniture to be dirty, facility walls and furniture in need of cleaning, and kitchen drawers to be broken which pose an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
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.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 03/10/2026 05:07 PM - It Cannot Be Edited


Created By: Gabriela Castro On 03/10/2026 at 01:24 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as chemicals were accessible to four (4) out of four (4) clients in care. LPA observed chemicals stored in an unlocked kitchen cabinet and additional chemicals stored unlocked in the laundry room cabinet which pose an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
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.
Type A
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the facility restrooms were observed to be dirty and grimy which pose an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
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.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 03/10/2026 05:07 PM - It Cannot Be Edited


Created By: Gabriela Castro On 03/10/2026 at 01:24 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the facility did not have the required sufficient supply of at least two (2) days of perishable food available for residents which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
Licensee shall ensure the facility maintains a sufficient supply of at least two (2) days of perishable food for residents at all times.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as medications were stored in an unlocked cabinet in the kitchen, and the administrator did not have the key to secure the cabinet which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 03/11/2026
Plan of Correction
1
2
3
4
Licensee shall ensure that all medications are stored in a locked cabinet or area that is inaccessible to clients at all times.
**POC cleared during visit** Administrator located the key to the medication cabinet and secured the cabinet during the visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 03/10/2026 05:07 PM - It Cannot Be Edited


Created By: Gabriela Castro On 03/10/2026 at 01:24 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as all window sills throughout the facility were observed to be filled with visible dirt which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Licensee shall ensure that the facility is maintained in a clean and sanitary condition at all times. Licensee shall clean all window sills throughout the facility to remove visible dirt
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as nightlights were not installed in the facility hallways which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Licensee shall ensure that nightlights are installed and maintained in all hallways used by residents to provide adequate lighting during nighttime hours.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
Page: 6 of 13
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: 03/10/2026
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
 Food Service

Refrigerators and freezers are required to be maintained at proper temperatures (refrigerators at a maximum of 40°F and freezers at 0°F) and must contain a sufficient supply of at least two (2) days of perishable food and seven (7) days of non-perishable food. During the inspection, LPA observed that the refrigerator located in the kitchen was not functioning due to the lack of electricity in that portion of the facility. LPA did not observe any perishable food available in the home. The administrator reported that the detached garage is not accessible to clients; however, LPA observed additional working refrigerators located in the garage containing frozen foods and leftovers that were not properly covered and it did not contain perishable food items.

Health-Related Services & Records:
Three (3) client files were reviewed and contained current required documents (Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status, Rights acknowledgments, and IPPs). Medical/dental care was current. Three (3) medications were reviewed; medications are centrally stored in locked cabinet in the kitchen, locked, and labeled.

Disaster Preparedness:
Last fire/earthquake drills were not available. LIC 610D Emergency Disaster Plan was posted in living room area.

Personnel Records & Training:
Five (5) staff files were reviewed and included criminal record clearances, CPR/First Aid, DSP training, and TB screenings. Administrator Certificate for Robert Williams was pending renewal. LPA confirmed in CCLD website on pending renewal.


An exit interview was conducted with Robert Williams, Administrator During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of the LIC 809D/809C, and appeal rights will be provided via email.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 03/10/2026 05:07 PM - It Cannot Be Edited


Created By: Gabriela Castro On 03/10/2026 at 02:14 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above as the facility does not maintain a log of disaster drills conducted at the facility which poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 03/31/2026
Plan of Correction
1
2
3
4
Licensee shall ensure that disaster drills are conducted and documented as required. Licensee shall begin maintaining a disaster drill log documenting the date of the drill, type of drill conducted, and participants involved.
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
Page: 13 of 13