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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320380
Report Date: 06/16/2023
Date Signed: 06/16/2023 02:15:21 PM

Document Has Been Signed on 06/16/2023 02:15 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:KINGSPINE SENIOR CARE HOMEFACILITY NUMBER:
198320380
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:5146 KINGSPINE RDTELEPHONE:
(714) 749-9353
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 5DATE:
06/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Katrina Buller, AdministratorTIME COMPLETED:
02:30 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) Ana Soto conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on 05/04/23 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) residents, (4) ambulatory, (1) non-ambulatory, and (1) bedridden. Structure: Facility is a (4) bedroom, one (2) full bathroom, single story house with front covered porch with small ramp, ramp in front of back door, ramp in front of back door of room C, back yard, and attached 2 car garage. The facility is a beige stucco with nice size backyard. Front yard landscape is in good condition. Back yard has a table, chairs, and umbrella, Laundry area with a working washer and dryer. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two residents per bedrooms. 4 Bedrooms are designated private bedrooms properly equipped with regulation guidelines of one bed, one chair, one night stand, one lamps and overhead lighting. Bedroom Staff: No staff bedroom. Bathrooms: 1 full bathroom located in the east side of facility between bedrooms C and D, 2nd bathroom is between bedrooms A and B, Both bathrooms have working toilets and wash basins. Bathrooms also contain grab bars, folding bench/chair, and non-skid mats. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway cabinet. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in the north hallway. Facility has a land line telephone located in the office. 1 Fire extinguishers, one 4A60BC mounted on the kitchen wall which is labeled, it is tagged with current annual checks.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KINGSPINE SENIOR CARE HOME
FACILITY NUMBER: 198320380
VISIT DATE: 06/16/2023
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
Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 6 hard wired smoke detectors, and 1 battery operated carbon monoxide detector located in the dining room are operational. Appliances: Stove, microwave, and washer/dryer, refrigerator are in working condition. The residence is equipped with central air and heat. Toxins: Cleaning supplies, and toxins are stored in two locations: in a locked cabinet inside the laundry area and cabinet bellow kitchen sink. Water Temperature: Water was tested in bathrooms and kitchen sink within 111.1 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in the laundry are under lock and key. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which is available for staff use. Resident & Staff Files: Designated area for files will be located in front of laundry area in a locked closet. Pools/Jacuzzi & Pets: No bodies of water and 4 cats on the premises. Fire Clearance: Fire clearance does indicate delayed egress or any locked perimeter. Component III: Waived at the time of Pre-Licensing.

No corrections needed.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2