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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603492
Report Date: 09/17/2026
Date Signed: 09/17/2026 02:28:03 PM

Document Has Been Signed on 09/17/2026 02:28 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/
DIRECTOR:		DREW, NICKIFACILITY TYPE:
740
ADDRESS:12703 MEADOW GREEN RDTELEPHONE:
(562) 448-3080
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
09/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Edjeska Macandili, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff Dante Serrano. Administrator Edjeska Macandili arrived later.

The following was observed during the inspection:

Infection Control: The facility has an Infection Control Plan that is reviewed annually.

Operational Requirements: A Dementia and hospice waiver for 6 residents has been approved. A fire clearance for 6 non-ambulatory of which 1 may be bedridden. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate expires 10/29/2026.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents. The facility consists of a kitchen, dining room, family room, living room, one (1) live-in staff bedroom, four (4) resident bedrooms, laundry area, and detached garage. Rooms are equipped with required furniture mattress pads, and bedding. Cleaning supplies and toxic substances are inaccessible to residents. The facility has fire extinguisher. Cleaning supplies and toxic substances are inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. First aid kits/Manuals are kept in activity rooms; consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze. Exit doors are free of any obstruction. The last Emergency Disaster drill was conducted on 8/10/2026.

*There are 2 staff living in the garage. The facility sketch and plan of operation do not indicate the garage is permitted as an additional dwelling unit. The side gate door had a lock. citation was issued. Indoor surveillance cameras were observed; a technical advisory was issued.

Lisa Hicks
Noemi Galarza
DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2026
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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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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KINGDOM WORKS
FACILITY NUMBER: 198603492
VISIT DATE: 09/17/2026
NARRATIVE
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Staffing: A total 6 staff members provide care and supervision to the residents.

Personnel Records/Staff Training: Six files were reviewed. Files were reviewed for criminal background clearance, training, health clearance, and 1st Aid/CPR training. Administrator certificate expires 7/28/2027.

* Administrator on record is not current. A citation was issued.

Resident Records/Incident Reports: A total of six (6)resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent.

RCFE complaint poster and Personal rights were observed posted. However, the RCFE complaint poster is not the correct size i.e., 20 x 24. A Technical Advisory was issued.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. No residents require modified diets.

Incident Medical and Dental: Centrally Stored Medication And Destruction Record/ 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family. The facility uses electronic Medication Administration Records (MARs).

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: All residents are enrolled in home health services.

Pursuant to Title 22, deficiencies were cited.


An exit interview was conducted with . A copy of the report/appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/17/2026 02:28 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/17/2026 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGDOM WORKS
FACILITY NUMBER: 198603492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that resident (R1's) bed has full rails, but the resident is not enrolled in hospice care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2026
Plan of Correction
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Administrator agreed to obtain a physician order for half bed rails. Half rails were installed on the bed during the visit. Submit a copy of the physician order and proof of staff training.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because the gate door located between the house and detached garage was locked with a lock that requires a key, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2026
Plan of Correction
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Administrator immediately removed the lock from the gate. Submit proof of staff training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/17/2026 02:28 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/17/2026 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGDOM WORKS
FACILITY NUMBER: 198603492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(g)
Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the current Administrator was hired on 4/16/2025 and licensee did not notify the Department within 30 days, nor has submitted change of Administrator documents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2026
Plan of Correction
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Licensee shall submit change of Administrator request and documents to the Department.
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onobservation, the licensee did not comply with the section cited above in that staff (S2 & S3) are living in a room located in the garage; an additional bed was observed next to the room. The facility sketch and plan of operation do not indicate the garage is permitted as an ADU, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2026
Plan of Correction
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Licensee shall submit:
1. A written plan of correction stating how the citation will be corrected. For example, if licensee plans to obtain an ADU permit for the garage submit proof of contact with City of La Mirada planning department.
2. Update the Plan of Operation and facility sketch if applicable. NOTE: The current plan of operation and facility sketch do not state the garage will be used as a dwelling for live-in staff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2026


LIC809 (FAS) - (06/04)
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