<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200723
Report Date: 03/30/2022
Date Signed: 03/30/2022 11:56:27 AM

Substantiated


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
03/16/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210316144311
FACILITY NAME:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR:ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 4DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Alanna Spencer, AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff failed to treat residents with dignity and respect.
-Staff yelled at resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/30/2022 at 9:40 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct complaint investigation for above allegations. Upon arrival, LPAs were greeted by Counselor, Deshane Johnson and explained the purpose visit. Administrator, Alanna Spencer later arrived at 10:35 AM.

During the complaint investigation, LPAs obtained information, collected documents and interviewed 4 staff. It was alleged staff failed to treat residents with dignity and respect, and staff yelled at resident. Based on recordings obtained, LPAs heard S1 yelling and cursing at C1. During an interview with S4, LPAs discovered there was another incident where S1 engaged in an argument with another client.


REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20210316144311
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: 03/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20210316144311
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited
CCR
81072(a)(1)
1
2
3
4
5
6
7
PERSONAL RIGHTS OF RESIDENTS....
(a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to review regulation and conduct in-service training with all staff and submit a copy of training agenda with staff signatures to CCL by POC date.
8
9
10
11
12
13
14
Based on interview and recordings obtained, Licensee did not comply with the regulation above. LPAs heard S1 cursing at C1 on the recording which poses a potential personal rights to persons in care.
8
9
10
11
12
13
14
Type B
04/08/2022
Section Cited
CCR
81072(a)
1
2
3
4
5
6
7
PERSONAL RIGHTS OF RESIDENTS....
(a) Each client shall have personal rights which include, but are not limited to, the following:

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to review regulation and conduct in-service training with all staff and submit a copy of training agenda with staff signatures to CCL by POC date.
8
9
10
11
12
13
14
Based on interview and recordings obtained, Licensee did not comply with the regulation above. LPAs heard S1 yelling at C1 on the recording which poses a potential personal rights to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3