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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320380
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:59:34 PM

Document Has Been Signed on 07/11/2024 04:59 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:KINGSPINE SENIOR CARE HOMEFACILITY NUMBER:
198320380
ADMINISTRATOR/
DIRECTOR:		BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:5146 KINGSPINE RDTELEPHONE:
(714) 749-9353
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 6DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:32 PM
MET WITH:Angel VillaranteTIME VISIT/
INSPECTION COMPLETED:
05:03 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
On 07/11/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Angel Villarante, Caregiver (S1) and explained the purpose of today’s visit. The facility is licensed as a Residential Care For Elderly (RCFE) that serves residents 60 years and above. The capacity is for six (6) residents which consist of the following: four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden resident.
The facility is a single-story house, located in a residential neighborhood and consists of four (4) bedrooms and two (2) full bathroom. Backyard has a shaded area with a table and chairs. The laundry area has a working washer and dryer.
LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature in the kitchen measured 112.7 degrees F and bathroom number one (#1) was measured at 106 degrees F and a comfortable temperature of 75.3 degrees F was maintained in the facility.

Due to time constraints, LPA has decided to complete this annual inspection during a future, unannounced, date.

There has been two deficiencies cited during today's visit, please see LIC809D.

An exit interview was conducted with Angel Villarante and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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
Document Has Been Signed on 07/11/2024 04:59 PM - It Cannot Be Edited


Created By: Mario Leon On 07/11/2024 at 04:44 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINGSPINE SENIOR CARE HOME
FACILITY NUMBER: 198320380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in having garage needs to be maintained by cleaning out extra junk, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
LPA and Alan Palisoc (S2) have agreed that facility will clean out the garage trash in order to prevent insect/vermin infestation. Facility will send updated photo evidence to LPA via email at MARIO.LEON@DSS.CA.GOV on or prior to the POC due date which is 07/19/2024
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in having tears of the back door(s) and room A window screens need to be replaced, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
1
2
3
4
LPA and Alan Palisoc (S2) have agreed that facility will replace the screens in above-mentioned locations in order to prevent insects/vermin entry. Facility will send updated photo evidence to LPA via email at MARIO.LEON@DSS.CA.GOV on or prior to the POC due date which is 07/17/2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


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