019200723-12-1-2021-15-AS-KHOS-CA4QYT-20211227113539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200723
Report Date: 12/01/2021
Date Signed: 12/01/2021 05:41:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200511131410

FACILITY NAME:	KIMBILIO		FACILITY NUMBER:	019200723
ADMINISTRATOR:	HENDERSON, JASON		FACILITY TYPE:	772
ADDRESS:	1480 159TH STREET		TELEPHONE:	(510) 301-5809
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	14	CENSUS: 8	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Jonathan Haskins, Caregiver		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Clients are overdosing with the use of illegal drugs at the facility
Staff yelled at client
Client sustained an injury while in care.
Staff failed to seek medical attention in a timely manner.
Staff falsified documents
Staff failed to refill client's prescription in a timely manner
Staff failed to meet clients' needs

INVESTIGATION FINDINGS:

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On 12/1/2021, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to conduct an complaint investigation and to deliver complaint findings for the above allegations. LPAs met with Jonathan Haskins, Caregiver, and explained the reason for the visit. Alaana Spencer, Administrator later arrived at 3:55PM.

Based on record reviews and interviews by the Department, The allegation of clients are overdosing with the use of illegal drugs at the facility was accepted by the Department's Investigations Branch (IB) as a full investigation. The Department conducted interviews with both former and current clients, staff and reviewed records. Based on the investigation, the medical records from several Alameda County hospitals, Alameda County Sheriff’s Office calls for service and Falck Ambulance patient care reports do not

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200511131410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KIMBILIO	FACILITY NUMBER: 019200723
	VISIT DATE: 12/01/2021

NARRATIVE

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Continued from LIC9099.

indicate that any of the clients the Reporting Party (RP) informed the Department of had overdosed in the facility. Although, some of the clients did drugs or drank alcohol outside of the facility and later returned to the facility intoxicated or passed out inside the facility despite the facility's no drug and alcohol policy.

For the allegation staff yelled at resident. LPAs interviewed four (4) out of eight (8) current clients. All clients stated that none of the staff have ever yelled or spoke inappropriately to them. The Department interviewed four (4) out of five(5) previous clients during investigation and one (1) of the four (4) indicated one staff had spoken harshly with client.

For the allegation, client sustained and injury while in care. Interviews with S9 and staff indicated that S9’s injury occurred outside of the facility. S9 stated he tripped and fell four hours prior while walking, walked back to the facility, staff observed S9 bleeding and called the ambulance.
For the allegation, facility failed to seek medical attention in a timely manner. LPA reviewed statements of four (4) out of the (5) clients that were interviewed and staff. All statements indicated that staff would arrange for medical treatment in a timely manner if needed or requested.

For the allegation, Staff falsified documents. LPAs interviewed staff and it was stated that there are times were documents are put aside for required signature from a specific staff member. LPAs reviewed four (4) out of eight (8) present clients and did not observe any missing signatures or dates.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200511131410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KIMBILIO	FACILITY NUMBER: 019200723
	VISIT DATE: 12/01/2021

NARRATIVE

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Continued from LIC9099C.

For the allegation, Staff failed to refill prescription in a timely manner. LPA interviewed S9 and it was disclosed that client would speak with doctors to have medication changed or discontinued. Staff did not have any issues refilling medication. LPAs reviewed client’s file and did not observe any notes indicating client missing medication.

For the allegation, Staff failed to meet clients needs. Based on record review, observations and interviews all clients can perform all their own ADLs. During interviews with staff it was stated that clients are encouraged to upkeep their hygiene, but it does not always happen. Present clients stated their needs are being met during interviews.

LPAs obtained the following documents: client roster, staff roster and schedule.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Eixt interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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