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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200723
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:36:58 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
02/21/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240221091713
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: 7DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jonathan HaskinsTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff failed to prevent a male resident from sexually harassing female residents verbally
INVESTIGATION FINDINGS:
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On this day at around 2:45 pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Patricia Manalo arrived unannounced to deliver finding for the above allegation. LPAs met with Case Manager Jonathan Haskins. LPAs explained to Haskins the purpose of the visit. Program Director Marla Henderson was informed about the visit and authorized Haskins to sign the report.

During the course of investigation, Oakland Adult and Senior Care Program Regional Office (RO) referred the case to Investigations Branch (IB). IB conducted interviews, obtained and reviewed records.
On 2/29/2024, the Department contacted the Alameda County Sheriff’s Office. Based on interview conducted with the sheriff’s office, the deputy who responded determined there was no sexual harassment to the Reporting Party (RP), the sexual harassment to other clients was secondhand information and that Resident 1 (R1) had moved out of the facility. The deputy closed out the case as unfounded and no report was taken. The deputy’s notes state that R1 “exposed self to R2 and R4, neither R2 nor R4 sought a complaint, and they just wanted advice.” continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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-20240221091713
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: 09/12/2024
NARRATIVE
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Based on record review conducted, the Department obtained an unusual occurrence report dated 1/16/2024 indicating R1 “flirting with female clients and staff, does not stop when asked, staff and female clients do not feel safe as R1 will not stop. An unusual incident report dated 1/16/2024 was also obtained by the Department stating R1 making sexual advances towards Staff 1 (S1), other female staff and clients. The report also states that Program Director and client clinician were informed.

Based on interview conducted by the Department with Resident 2 (R2), R1 would follow R2 and R4 around the house and asked sexual questions. R1 would ask R2 and R4 for hugs and sometimes R1 would block the hallways with arms wide open asking for a hug. R1 would stare at them and put his hands in his pants and touch genitals while making sexual comments. R2 states R1 was doing the same thing to female staff. R2 states R1 never touched R2 and R4 but was very persistent.

On 2/25/2024, the Department received information from R2 via email that R1 “has been harassing R2 and R4.”

On 3/5/2024, the Department interviewed R3 who states that R3 witnessed R1 “jerking off …pants and cornering R2 in the kitchen.” R3 states R1 would not stop despite R2 telling R1 to stop. When R3 told R1 to stop, R1 finally stopped and mumbled threats against R3.

R3 states R1 never touched R3 and most of the harassments were towards R2 and R4.

On 3/5/2024, the Department interviewed S1 who was aware of the situation in the house between residents. S1 was made aware of the situation by other staff members. S1 never witnessed R1 sexually harassing the female residents.

Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.



Exit interview was conducted with Haskins and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
02/21/2024 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240221091713

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: 7DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jonathan HaskinsTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff did not comply with resident's admission agreement
INVESTIGATION FINDINGS:
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On this day at around 3:30 pm, LPAs L. Fontanilla and P. Manalo delivered finding for the above allegation and met with Case Manager Jonathan Haskins. LPAs explained to Haskins the purpose of the visit.

During the course of investigation, the Department conducted interviews and reviewed records.

The Department interviewed Resident 3 (R3) and Staff 1 (S1). S1 states that R3 requested the Program Director for a grievance form. The Director didn’t have the form on hand but got it to R3 two to three days later. R3 states that it took the staff three weeks to supply the grievance report form.

A review of the facility’s agreement indicates, “If a resident wishes to file a complaint, the Grievance policy and forms are available in the staff office.” The agreement does not indicate how much time the facility has to provide the grievance form to a resident.
continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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-20240221091713
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: 09/12/2024
NARRATIVE
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LPA was unable to interview the former Administrator as he has resigned from the facility.

Due to conflicting information obtained, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There is no deficiency noted.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20240221091713
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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2024
Section Cited
CCR
81072(a)(1)
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81072(a)(1) PERSONAL RIGHTS
(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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A Non Compliance Conference (NCC) will be conducted on 9/17/2024 to discuss plans of correction.
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This requirement is not met as evidenced by: Based on interviews and record reviews conducted, the facility did not prevent R1 from sexually harassing female clients from January till March 2024 which poses an immediate risk to the health and safety of clients under 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5