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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603492
Report Date: 10/04/2021
Date Signed: 10/04/2021 04:11:48 PM

Document Has Been Signed on 10/04/2021 04:11 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KINGDOM WORKSFACILITY NUMBER:
198603492
ADMINISTRATOR:DREW, NICKIFACILITY TYPE:
740
ADDRESS:12703 MEADOW GREEN RDTELEPHONE:
(562) 448-3080
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 0DATE:
10/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Applicant Nicki Drew TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an announced visit with applicant Nicki Drew. The purpose of the visit was to conduct the Pre-Licensing visit.

An application was submitted to CCLD on 7/24/2021, for an Initial License of a Residential Care Facility for the Elderly for ages 60 years and older. The requested capacity of 6 residents, (0) ambulatory, (5) non-ambulatory and (1) may be bedridden.

Structure/Physical Plant:
The facility is a single story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage cabinet for medications and sharps, (4) resident rooms, (1) live in staff room, (3) bathrooms; each bathroom with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. A detached garage inaccessible to residents for storage, a washer and dryer. The residence is equipped with central air and heating.

Accommodations: Adequate accommodations observed throughout facility. Lighting: Sufficient Lighting throughout. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: Bedroom #1 for (2) residents one (1) of which may bedridden. Bedrooms #2 and #4 are for (1) non-ambulatory resident each . Bedroom #3 is for (2) non ambulatory clients. There is (1) Bedroom used for live in staff. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: Bathroom #1 is attached to bedroom #1. Bathroom #3 is attached to bedroom #3. Bathrooms #1, #2, and #3 all have a working toilet, wash basins, showers, grab bars and nonskid mats.
Linens & Hygiene Supplies: Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed.

Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KINGDOM WORKS
FACILITY NUMBER: 198603492
VISIT DATE: 10/04/2021
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Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is (1) cordless phone for residents use. Fire Extinguisher 1,2, and 3 fully charged and up to date. Exit plan posted. Food Menu observed. Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Knives, cutlery and other sharps inaccessible to residents will be kept in a locked cabinet. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working. Smoke detectors and also carbon monoxide detectors observed, all detectors tested and operational. (3) Fire extinguishers observed and up to date. Appliances: Stove burners and oven operational. Microwave, washer, and dryer are operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -120 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to resident. First aid kit inspected which contains: thermometer, tweezers, scissors, antiseptic, bandages, gauze, which is available for staff use. First aid manual observed Residents & Staff Files: Facility has a locked cabinet for resident and staff files. Sample files were observed. Reading Material, Games, Equipment & Materials, Postings: The facility has activity supplies and an activities calendar posted. Required wall postings observed. Bodies of Water: None. Pets: None. Fire clearance: Fire clearance was approved on 6/7/21.

Physical Plant is cleared at the time of visit.

Component III:
Component III was conducted at the time of this visit with applicant Nicki Drew.

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 Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC809 (FAS) - (06/04)
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