374603787-11-15-2024-18-AS-VMIN-DB2Q69-20241115105311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603787
Report Date: 11/15/2024
Date Signed: 11/15/2024 10:53:23 AM

Document Has Been Signed on 11/15/2024 10:53 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	KINGS CARE ASSISTED LIVING LLC		FACILITY NUMBER:	374603787
ADMINISTRATOR/ DIRECTOR:	YERKO, MARK		FACILITY TYPE:	740
ADDRESS:	247 PRESLEY PLACE		TELEPHONE:	(760) 643-1557
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	ADMINISTRATOR, LUANN LOZANO		TIME VISIT/ INSPECTION COMPLETED:	10:58 AM

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	On November 15, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection, and met with the Administrator, LuAnn Lozano. The facility file review was conducted in the Regional Office and additional records were requested and reviewed on site. LPA Mixson toured the facility, along with the Administrator, LuAnn Lozano, and inspected the inside and outside of the facility. There were no obstructions to indoor and/or outdoor passageways at the time of this visit. The facility is a two-story home, located at 247 Presley Place Vista, CA. 92083. Physical Plant: The facility is not operating in the capacity approved by Community Care Licensing, which is 14, but has five residents at the time of this visit. The facility phone number is (760)643-1557 and is operable currently. LPA observed a sample of the resident's bedrooms, and those reviewed were equipped with required furniture, including bed & mattresses, nightstands, storage space, and sufficient lighting. LPA inspected two bathrooms, and the hot water temperature tested within regulations. The bathrooms were clean, and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and a fire extinguisher. Posters such as the Ombudsman and CCL complaint poster were posted in a common area. The cleaning supplies, toxins, and sharps were kept inaccessible to residents in care. There was a designated storage space for resident and staff files, and it was locked and inaccessible to residents.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Venus Mixson	TELEPHONE: (951) 897-7936
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KINGS CARE ASSISTED LIVING LLC	FACILITY NUMBER: 374603787
	VISIT DATE: 11/15/2024

NARRATIVE

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Medications: The medication are delivered from the pharmacy and were locked and inaccessible to the residents. The overall facility is clean, in good repair, and operating in safe conditions for residents currently at the time of this visit.

Food Service: Non-perishable and perishable food supply is sufficient for the number of residents, and there are a variety of food types available for the residents. Dishes and utensils were also stored properly.

Care & Supervision: Facility has sufficient staff, and staff were engaging the residents during this visit and attending to the morning meal and assisting with medications.

Record Review: LPA Mixson reviewed five staff records and five resident records.
The required forms were present currently at the time of this visit.

There was observable Title 22, Division 6 Regulation violations observed and/or cited during today’s visit, as they pertained to facility staff not receiving the required amount of annual training as it pertained to the care of residents receiving Hospice care.

An exit interview was conducted, and a copy of this report was discussed and given to the Administrator, LuAnn Lozano.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KINGS CARE ASSISTED LIVING LLC	FACILITY NUMBER: 374603787
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited

(c) The training shall include, but not be limited to, all of the following: (7) Dementia care, including the use and misuse of antipsychotics, the interaction of drugs commonly used by the elderly, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review)], the licensee did not comply with the section cited above in [4] out of [6 count] [(Staff)] [ training was not obtained two hours of the annual training.] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2024
	Plan of Correction
1 2 3 4	Administrator will provide all facility staff with training as listed above, by the 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Venus Mixson	TELEPHONE: (951) 897-7936
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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