Kingspine Senior Care Home

Type of visit: Annual/Random

On 09/08/26, the department conducted an unannounced 1-year required annual visit to this facility. The department met with Rodolfo Jaca, Caregiver, and the purpose of the visit was explained. The facility is licensed to serve 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 has a hospice waiver for six (6) residents. Currently, the home has (6) residents. The facility is a single-story residential home located in a residential neighborhood. The home consists of the following: four (4) bedrooms, two (2) bathrooms, kitchen, living room, dining area, laundry area, attached garage, and a backyard. The department conducted a records review of six (6) resident service records, four (4) staff records, and reviewed the facilities emergency disaster plan. All resident and staff records were complete and in order. The facility emergency disaster plan was current and in compliance with Title 22 regulations at the time of visit. The department reviewed three (3) resident Medication Administration Records (MAR) and medication and did not observe any discrepancies at the time of visit. The department conducted a tour of the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident bedrooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for resident’s personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Continued LIC9099-C Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries are accessible to residents. The water temperature properly measured between 105.0 F degrees and 120.0 F degrees. A comfortable temperature is maintained in the facility. The department observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to residents. The kitchen was inspected and there is enough perishable and non-perishable food available for the residents. All food items were stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manual. The fire extinguishers were fully charged, and the smoke/carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 06/02/26. A valid administrator certificate for Alyssa Gutierrez, #7037117740, effective 04/18/26, and expires 04/17/28. The facilities liability insurance from Built Insurance Brokerage, policy #PCI94425188-04, is valid from 07/11/26 through 07/11/27. During the visit, the department observed the facility’s infection control practices. The department observed screening protocols for visitors, staff, and residents. The department observed that sanitizing stations were in common areas and restrooms. The department observed that the facility had the required postings, posted throughout the facility. No deficiencies were cited during this inspection visit. Please note that due to technical difficulties, the department was unable to generate an electronic inspection tool and instead used a printable/PDF version. An exit interview was conducted, and a copy of this Facility Evaluation Report was provided.the state’s words, verbatim · CDSS document, Sep 8, 2026

Type of visit: Required - 1 Year

On 08/13/25, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required inspection visit to Kingspine Senior Care Home. LPA met with Alyssa Gutierrez, Administrator, and explained the purpose of today’s visit. The facility is licensed to serve 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 has a hospice waiver for six (6) residents. Currently, the home has (6) residents. The facilities annual fees are current. The facility is a single-story residential home located in a residential neighborhood. The home consists of the following: 4 bedrooms, 2 bathrooms, kitchen, living room, dining area, laundry area, attached garage, and a backyard. LPA conducted a records review of (6) resident records, (5) staff records, and reviewed the facilities emergency disaster plan. All resident and staff records were complete. The facility emergency disaster plan was current and in compliance with Title 22 regulations at the time of visit. LPA reviewed (6) resident medication administration records and medication, and did not observe any discrepancies at the time of visit. At 10:00am, LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for resident’s personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Report Continued on LIC809-C Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries are accessible to residents. The water temperature measured 108.9F degrees; a comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to residents. The kitchen was inspected and there is enough perishable and non-perishable food available for the residents. All food items were stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manual. The fire extinguishers were charged and last inspected on 03/06/2024, and the smoke/carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 06/05/2025. The facilities administrator’s certificate was valid from 04/18/2024 through 04/17/2026. The facilities liability insurance was valid from 07/11/2025 through 7/11/2026. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA advised the facility to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this Facility Evaluation Report was provided to Alyssa Gutierrez, Administrator.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Staff are not ensuring that resident's incontinence needs are being met Staff are not trained on maintaining resident's hygiene

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 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. 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.the state’s words, verbatim · CDSS document, Jun 26, 2025 · control 11-AS-20241227125646

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Jul 4, 2025

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 wetthe state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: 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. Licensee will forward updated change log and all staff annual trainings, previously conducted, of 2025 to LPA at MARIO.LEON@DSS.CA.GOV

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Jul 4, 2025

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 been met as evidenced by: One staff (S1) confirming they have used improper infection control method(s).the state’s words, verbatim · CDSS document, Jun 26, 2025

Plan of correction: 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 MARIO.LEON@DSS.CA.GOV

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jul 11, 2024