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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320380
Report Date: 09/08/2026
Date Signed: 09/08/2026 12:51:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/08/2026 12:51 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:KINGSPINE SENIOR CARE HOMEFACILITY NUMBER:
198320380
ADMINISTRATOR/
DIRECTOR:		BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:5146 KINGSPINE RDTELEPHONE:
(714) 749-9353
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 6DATE:
09/08/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Rodolfo JacaTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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 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

Stephanie Cifuentes
Elvira Gonzalez
DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINGSPINE SENIOR CARE HOME
FACILITY NUMBER: 198320380
VISIT DATE: 09/08/2026
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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.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC809 (FAS) - (06/04)
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