198603492-10-20-2023-28-AS-JVIS-CWSQ3F-20231020114840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603492
Report Date: 10/20/2023
Date Signed: 10/20/2023 11:49:20 AM

Document Has Been Signed on 10/20/2023 11:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	KINGDOM WORKS		FACILITY NUMBER:	198603492
ADMINISTRATOR:	DREW, NICKI		FACILITY TYPE:	740
ADDRESS:	12703 MEADOW GREEN RD		TELEPHONE:	(562) 448-3080
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 5	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Nicki Drew		TIME 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 Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Nicki Drew. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility approved Infection Control Plan.

Operational Requirements:

A current Plan of Operation with Infection Control Plan observed. Dementia Care Plan on file
A fire clearance for 6 residents of which (6) may be non ambulatory; 1 may be bedridden.
Hospice care waiver approved for six (6) residents.

Physical Plant/Environment Safety:

The facility is a single story home located in a residential area and contains the following: living room, dining room, kitchen, (4) resident rooms, (1) live in staff room, (3) bathrooms. A back yard with shaded area and seating for resident use. A detached garage inaccessible to residents for storage, a washer and dryer. The residence is equipped with central air and heating. Fire alarms operational
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

A total of 5 staff members provide supervision to the residents.
Sufficient staff observed during visit

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGDOM WORKS	FACILITY NUMBER: 198603492
	VISIT DATE: 10/20/2023

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

Personnel Records/Staff Training:

Administrator on file is current.
Staff have criminal background clearance and training.
Three (3) staff files were reviewed. Required training observed

Resident Records/Incident Reports:

A total of five (5) resident files were reviewed.
Required postings observed

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Activities supply observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Incident Medical and Dental:

Emergency transportation available
First Aid Kid observed
(5) of (5) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.

Residents with Special Health Needs:

Needs and Services Plan and Appraisals are on file.
Currently (2) resident receiving hospice services. Hospice care plan observed.
Orders for bed rails on file

Inspection Tool was completed and no deficiencies are being cited on todays visit.
Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2