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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200723
Report Date: 09/16/2025
Date Signed: 10/10/2025 01:16:11 PM

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
09/09/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250909103037
FACILITY NAME:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR:FRANK STARKSFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 7DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dwayne White, Administrator
Sam Camel, Facility Manager		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff engaged in an altercation in the presence of a resident in care
INVESTIGATION FINDINGS:
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On 10/10/25 at 12PM, Licensing Program Analysts (LPAs) D Panlilio and Y Brown conducted an unannounced complaint subsequent visit to amend the citation issued on 09/16/25. LPAs met with staff (ADM, S1) and explained the purpose of the visit. This report is an amendment of original complaint dated 09/16/25.

During investigation, LPAs obtained the following documents from ADM – Residents’ roster, Personnel Record (LIC500) / Work Schedules, Residents; admission agreement, physicians’ report, needs & services plan, incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 5
Control Number 15-AS-20250909103037
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: 09/16/2025
NARRATIVE
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Allegation: Staff engaged in an altercation in the presence of a resident in care
Investigation Finding: Substantiated
During investigation, LPAs interviewed staff (ADM, S1), reporting party (RP) and residents (R2, R3). On 09/11/25 at 9:22AM, RP confirmed with LPA Y Brown that another resident (R2) witnessed the altercation between the 2 staff (S1, S2) and kept telling R1 to stop getting involved. RP also stated that another resident (R3) recorded a video of the entire altercation between S1 and S2. LPAs reviewed the recorded video of the event and observed that both staff engaged in an altercation in the presence of other residents in care. Based on LPAs’ interviews and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) that staff engaged in an altercation in the presence of another resident was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250909103037
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: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2025
Section Cited
CCR
81072(a)(1)
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(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
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By POC due date, ADM agrees to complete and submit to CCL in-service staff retraining certifications on clients' personal rights in compliance with Section 81072 (a)(1)
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This requirement was not met as evidenced by staff engaging in an altercation in the presence of residents which posed a potential health & safety risk to residents in care.
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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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/09/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250909103037

FACILITY NAME:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR:FRANK STARKSFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 7DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dwayne White, Administrator
Sam Camel, Facility Manager		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff pushed a resident in care
INVESTIGATION FINDINGS:
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On 09/16/25 at 12PM, Licensing Program Analysts (LPAs) D Panlilio and Y Brown conducted an unannounced complaint visit and met with staff (ADM, S1). LPAs explained the purpose of the visit with staff. LPAs conducted interviews & record reviews and delivered investigation findings to ADM.

During investigation, LPAs obtained the following documents from ADM – Residents’ roster, Personnel Record (LIC500) / Work Schedules, Residents; admission agreement, physicians’ report, needs & services plan, incident reports.

Continued on next page, LIC 9099-C pg1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250909103037
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: 09/16/2025
NARRATIVE
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Allegation: Staff pushed a resident in care
Investigation Finding: Unsubstantiated
During investigation, LPAs interviewed staff (ADM, S1), reporting party (RP) and residents (R2, R3). LPAs contacted R1 on 09/12/25, 09/15/25, 09/16/25 for additional information and were unable to reach R1 who left the facility on 09/04/25 and never returned. ADM and S1 stated that they did not witness S2 push R1 during the staff altercation on 09/05/25. Review of recorded video dated 09/05/25 showed both staff (S2, S3) engaged in a heated argument with R1 trying to de-escalate the situation between them. LPAs also confirmed with staff (ADM, S1) and residents (R2, R3) that no physical pushing by S2 was observed. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff pushed a resident in care is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5