198603492-10-10-2024-28-AS-EZAA-D9WV9J-20241010161425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603492
Report Date: 10/10/2024
Date Signed: 10/10/2024 04:14:51 PM

Document Has Been Signed on 10/10/2024 04:14 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	KINGDOM WORKS		FACILITY NUMBER:	198603492
ADMINISTRATOR/ DIRECTOR:	DREW, NICKI		FACILITY TYPE:	740
ADDRESS:	12703 MEADOW GREEN RD		TELEPHONE:	(562) 448-3080
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 6		CENSUS: 5	DATE:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:01 PM
MET WITH:	Jesusa Soriano - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Jesusa Soriano, Cook/Caregiver for the facility, and explained the purpose of the visit. Administrator Nicki Drew arrived shortly thereafter. There are five (5) residents residing within the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices were observed.

· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for six (6) residents. The facility consists of a kitchen, a dining room, two (2) living rooms, one (1) staff bedroom, five (5) resident bedrooms, two (2) bathrooms of which restroom #1 had a hot water temperature of 110.6 Degrees Fahrenheit and restroom #2 had a hot water temperature of 105.2 Degrees Fahrenheit, along with a backyard that contains a shaded area and a detached garage. The facility was observed to be in good repair.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility.

· Water temperature readings for one of the bathrooms in the home fell within the required range of 105 - 120 degrees Fahrenheit.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGDOM WORKS	FACILITY NUMBER: 198603492
	VISIT DATE: 10/10/2024

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Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for six (6) residents.

· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Five (5) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.

· All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active.
· The administrator’s certificate expires on 4/27/2025.

Resident Rights/Information:

· Physician orders were reviewed for five (5) resident files.

· Medications were also reviewed for five (5) residents.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGDOM WORKS	FACILITY NUMBER: 198603492
	VISIT DATE: 10/10/2024

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Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted within the facility.

· The last emergency and disaster drill was conducted three (3) months ago.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· There are no residents currently receiving hospice services, home health services, or have a dementia diagnosis.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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