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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700136
Report Date: 11/18/2024
Date Signed: 11/18/2024 01:43:08 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/18/2024 01:43 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:KENSINGTON AGENCY, THEFACILITY NUMBER:
374700136
ADMINISTRATOR/
DIRECTOR:		DEAYDRE LEA PULLIAMFACILITY TYPE:
300
ADDRESS:8469 LA MESA BLVDTELEPHONE:
(619) 466-8773
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: CENSUS: DATE:
11/18/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Deadre Lea PulliamTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On November 18, 2024, Home Care Services Bureau (HCSB) Enforcement Analyst, Adrian Mangina arrived at the business office of Kensington Agency for a Biennial inspection. Upon arrival, the Enforcement Analyst identified herself and was greeted by Licensee Deaydre Lea Pulliam. Analyst Mangina observed the proper posting of business hours and license. Analyst was provided an area in which the review of personnel and administrative files could be performed. Licensee provided Analyst with current Certificate of Insurance showing that professional liability policy, worker's compensation, and dishonesty bond are current. Employee files were reviewed.

Upon completion of the file review the analyst discussed the findings of the inspection with Licensee Pulliam. The analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D forms. In addition, the licensee was provided a copy of the HCS9058 Appeal Rights form.

LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/18/2024 01:43 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 11/18/2024 at 12:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: KENSINGTON AGENCY, THE
FACILITY NUMBER: 374700136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2024
Section Cited
1796.44(b)(2)
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Training Requirements: (b) An affiliated home care aide shall complete a minimum of five hours of entry-level training prior to presence with a client, as follows:
(1) Two hours of orientation training regarding his or her role as caregiver and the applicable terms of employment.
(2) Three hours of safety training, including basic safety precautions, emergency procedures, and infection control
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #1 and #5 did not have proof of current entry-level training, a finding which poses an immediate health and safety risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2024 01:43 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 11/18/2024 at 12:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: KENSINGTON AGENCY, THE
FACILITY NUMBER: 374700136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2024
Section Cited
1796.44(c)
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Training Requirements:(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include, but not be limited to, the following areas:
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #4, #6 and #7 did not have current annual training, a finding which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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