Kingman Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Nilda Alpon. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. Kingman Care Home LLC is a level 4F home. LPA toured the facility inside out with Staff S1 which included the Living room, kitchen, dining room, 4 restrooms and 4 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. LPA toured the facility garage, which was being used as a storage area. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F and hot water temperature was measured at 109 degrees F in resident bathrooms. Fire extinguisher was serviced in January 6, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 15, 2025. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. Page 1 Out of 2. During visit, LPA Monter provided ADM with PIN 25-05-ASC Updated Medical Assessment for Residential Care Facilities for the Elderly (LIC 602A) Form. LPA requested the following documents for the change of administrator be sent to CCL by December 30, 2025. 1. Board of resolutions letter, stating the Date the new employee will begin working as Administrator and signed by the licensee, who is part of the corporation. 2. Administrators Certificate 3. LIC 501 4. Resume 5. LIC 500 6. LIC308. 7. LIC9182 8. Valid Photo ID No deficiencies cited during today's visit. This report was reviewed with Administrator Nilda Alpon and a copy of the signed report was provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Dec 22, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct the facility's annual required 1-year inspection. LPA met with House Manager/Designated Administrator, Avelina Pascua. During visit, LPA toured the facility with the staff to include the living room, dining room, kitchen, activity room, bathrooms, garage, resident bedrooms, staff bedrooms, and backyard. 6 clients observed in the facility. All fire exit routes were free and clear of obstruction. Carbon Monoxide detector present and operable. Fire extinguisher last serviced on 01/06/2025. Facility temperature maintained at 76 degrees F. All staff present are fingerprint cleared and associated to the facility. Resident bedrooms observed well maintained with beds, clean linens, dressers, night stands, and adequate lighting. The facility has an approved exception request for the use of a postural support for one resident. Bathrooms supplied with hygiene products, paper supples, and non-slid mats. Hot water temperature maintained at 118 degrees F in the bathroom next to the garage and office. Designated ADM states the bathroom in front of the office will be renovated to include a walk in shower. ADM states they will inform Licensing once renovation begins. Facility has 2 other showers to use for the residents while renovation is in place. 3 resident files were reviewed and observed complete. 3 resident's centrally stored medications and records observed maintained. 3 resident's P&I money was counted with ADM and no issues were noted. See LIC809-C. 3 staff files were reviewed and observed complete. 3 out of 3 staff has a 1st aid certification. 3 out of 3 staff has updated annual training to include topics of dementia, postural support, restricted health care condition, hospice care, and infection control. Facility has an infection control plan. Facility has an emergency disaster plan. Emergency drill last conducted on 11/2024 and the next drill is scheduled for 2/2025. LPA observed the facility has ready to go emergency bins which includes PPE supplies, non-perishable foods, and emergency lighting. LPA observed the facility has a complete first aid kit. Records to update the facility file is requested by 01/28/2025. Licensee received the list of documents to submit to licensing via email. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed House Manager/Designated Administrator, Avelina Pascua and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required 1-year inspection. LPA met with House Manager/Designated Administrator, Avelina Pascua. During visit, LPA toured the facility with the house manager to include the living room, dining room, kitchen, activity room, bathrooms, garage, resident bedrooms, and backyard. All fire exit routes were free and clear of obstruction. Carbon Monoxide detector present in the facility. Fire extinguisher last serviced on 01/10/2024. Facility temperature maintained at 78 degrees Fahrenheit. All staff present are fingerprint cleared and associated to the facility. Resident bedrooms observed well maintained with beds, clean linens, dressers, night stands, and adequate lighting. The facility has an approved exception request for resident (R3)'s postural supports. Bathrooms supplied with hygiene products, paper supples, and non-slid matts. Hot water temperature maintained at 112 degrees Fahrenheit in 2 out of 2 bathrooms. LPA reviewed 3 resident (R1 - R3) files to include an admission agreement, medical assessment, TB result, consent forms, emergency identification forms, safeguard personal property and valuables, and personal rights form. 3 out of 3 residents appraisal/needs and services plan were last updated in 2020. 2 out of 3 residents IPP was last updated in 2022. 1 out of 3 resident's file did not contain an IPP. Facility was advised. SEE LIC809-C. LPA reviewed 3 staff (S1 - S3) files to include an updated 1st Aid certification, health screening, TB information, employee rights, and personnel record. The facility was unable to produce staffs annual training to include dementia care, postural supports, restricted health conditions, and hospice care. The last training was completed in year 2022. Facility was advised. Facility's Emergency Disaster Plan was posted on the bulletin board located in the hallway and was dated in 2015 to include former staff members. LPA advised the house manager to update their emergency disaster plan. House Manager stated understanding. Facility has their facility sketch posted in a common area. Facility has extra flash lights and batteries. LPA observed the facility's first aid kit to be complete. Emergency drills are being conducted quarterly and the last drill was completed on 01/14/2024. Facility's Infection Control Plan was last updated in 2022. LPA advised the facility to update their infection control plan annually to ensure accuracy. Facility has a sufficient amount of PPE supplies, Posters and signs observed posted in common areas to include house rules, grievance, personal rights, complaint poster, ombudsman, and COVID-19 related resources. LPA interviewed 3 staff members. Documents were obtained to include the facility sketch and R3's admission agreement. LPA requested for the facility's certificate of liability insurance via email. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with House Manager/Designated Administrator Avelina Pascua and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 30, 2024