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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320380
Report Date: 06/26/2025
Date Signed: 06/26/2025 12:38:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241227125646
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:
06/26/2025
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Allan Palisoc - Lead CNA/CaregiverTIME COMPLETED:
01:03 PM
ALLEGATION(S):
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Staff are not ensuring that resident's incontinence needs are being met
Staff are not trained on maintaining resident's hygiene
INVESTIGATION FINDINGS:
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On 06/26/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings on the allegations listed above. LPA was met by staff one Allan Palisoc - Lead CNA/Caregiver (S1) and the purpose of the visit was explained.
The investigation consisted of the following:
On 12/30/24 LPA requested and reviewed facility documents, which included blood pressure log of two (2) residents, Medication Administration Records (MARs) of two (2) residents (R1, R4), Bowel Movement & Shower Chart of six (6) residents (R1-R6), Staff training log (S1-S3) and toured the facility inside and out with staff two (S2). LPA interviewed three (3) out of six (6) clients (R1-R3), four (4) out of ten (10) staff (S1-S4). Residents four, five and six (R4-R6) were not available for interview due to their medical condition. On 06/26/25 LPA further reviewed documents that were provided on 12/30/24.


Report continues, see LIC9099-C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 11-AS-20241227125646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198320380
VISIT DATE: 06/26/2025
NARRATIVE
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The investigation revealed the following:
Regarding the allegation, "Staff are not ensuring that resident's incontinence needs are being met", it is being alleged that the staff at the facility are not changing residents' incontinent supplies in a timely manner. Record reviews revealed that documentation of resident(s) in question have been completed; which include their MAR(s) for the months of November and December, showering chart dating back to 12/02/24 and "diaper change" log which dates to 12/28/24. LPA interviews revealed that two staff (S1-S2) agree that one resident has been discovered in soiled linens. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D.

Regarding the allegation, "Staff are not trained on maintaining resident's hygiene", it is being alleged that the staff at the facility are not trained on maintaining resident's hygiene. Record reviews revealed that documentation of resident(s) in question have been completed; which include their MAR(s) for the months of November and December, showering chart dating back to 12/02/24 and "diaper change" log which dates to 12/28/24. LPA interviews revealed that a staff (S1) has confirmed they use baking soda mixed with water to clean a resident's infection. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D.

An exit interview was held with staff one, Allan Palisoc - Lead CNA/Caregiver (S1), and a copy of facilities' appeal rights, these two (2) deficiencies and this report have been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20241227125646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198320380
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2025
Section Cited
CCR
87625(b)(3)
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87625 - Managed Incontinence
(b) In addition to Section 87611,..., the licensee shall be responsible for the following:(3) Ensuring that incontinent residents...kept clean and dry...from incontinence. This has not been met as evidenced by: two (2) staff confirming a resident was discovered as wet
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LPA and Administrator have agreed that staff will create an updated "diaper change log", with date and timestamp, after receiving one (1) hour in-service training from hospice nurse (RP), regarding "Hospice 101, Dementia and Skin Breakdown" on 12/30/2024.
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Licensee will forward updated change log and all staff annual trainings, previously conducted, of 2025 to LPA at MARIO.LEON@DSS.CA.GOV
Type B
07/04/2025
Section Cited
CCR
87468.2
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87468.2 Additional Personal Rights of Residents...facilities (a) In addition to...87468.1,...,...the elderly shall have... personal rights: (4) To care, supervision, and services...and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This has not
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LPA and Administrator have agreed that staff will conduct an in-service training on infection control measures, pertaining to both skin breakdown and physical plant cleanliness. Administrator will forward these in-service trainings, and all in-service tranings that have been conducted since 12/31/2024 to LPA at
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been met as evidenced by: One staff (S1) confirming they have used improper infection control method(s).
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MARIO.LEON@DSS.CA.GOV
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241227125646

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:
06/26/2025
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Allan Palisoc - Lead CNA/CaregiverTIME COMPLETED:
01:03 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure the facility is clean and sanitary
Staff are not ensuring that resident is receiving medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/26/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility to deliver findings on the allegations listed above. LPA was met by staff one, Allan Palisoc - Lead CNA/Caregiver (S1), and the purpose of the visit was explained.
The investigation consisted of the following:
On 12/30/24 LPA requested and reviewed facility documents, which included blood pressure log of two (2) residents, Medication Administration Records (MARs) of two (2) residents (R1, R4), Bowel Movement & Shower Chart of six (6) residents (R1-R6), Staff training log (S1-S3) and toured the facility inside and out with staff two (S2). LPA interviewed three (3) out of six (6) clients (R1-R3), four (4) out of ten (10) staff (S1-S4) and one witness (W1). Residents four, five and six (R4-R6) were not available for interview due to their medical condition. On 06/26/25 LPA further reviewed documents that were provided on 12/30/24.

Report continues, see LIC9099-C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20241227125646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 198320380
VISIT DATE: 06/26/2025
NARRATIVE
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The investigation revealed the following:
Regarding the allegation, "Staff do not ensure the facility is clean and sanitary", it is being alleged that a resident's family member(s) have observed the facility to be in disrepair, which have included toilet paper and cat vomit on the bathroom floor. Upon entry to the facility, LPA made the following observation; showers in the facility, primaily for use of residents, are without mold and window sills and screens are in clean, working, condition. Floors appear to be clean and tidy and LPA smelled a clean and fresh scent in the toilet(s) room(s). Interviews have revealed that all staff (S1-S4) have confirmed that it is the staff's job to keep the facility clean, and in tidy fashion, and that all staff will continue to make sure the facility is being kept clean. Based on LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation, "Staff are not ensuring that resident is receiving medication as prescribed", it is being alleged that a resident has not been receiving their insulin medication. Record reviews have revealed the following: Resident one (R1) medication administration record (MAR) (dated: 12/2024) appeared to be complete, specifically, on the date in question which was 12/26/24. Interviews have revealed the following: all four staff (S1-S4) have confirmed they are to provide residents their medication in a professional and timely manner. All three (R1-R3) residents have confirmed that they do receive their medication at the appropriate time. Based on LPA Record Reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was held with staff one, Allan Palisoc - Lead CNA/Caregiver (S1), and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5