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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200723
Report Date: 03/04/2025
Date Signed: 03/04/2025 12:26:50 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
02/16/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240216091925
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: 6DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:JONATHAN HASKINS, FACILITY CASE MANAGERTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
\Uncleared staff working at the facility.
INVESTIGATION FINDINGS:
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On 03/03/2025 at 10:30AM, Licensing Program Analysts (LPAs) Carol Fowler and Yasamin Brown arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPAs met with Jonathan Haskins, Facility Case Manager and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with client 1, clients 2 and 3 were not available, Staff 1, 2, 5, 6 and 7. LPA reviewed and received a copy of Client 1 records. LPA toured the facility with Staff 1.

Uncleared staff working at the facility.
RP stated that there was uncleared staff working at the facility. Record review of Guardian and facility LIC500 revealed that S4 was working NOC shift and was not fingerprint and associated to the facility. Interview with S2 revealed that S4 was working NOC shift at the facility. Therefore the allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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 6
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
02/16/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240216091925

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: DATE:
03/04/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jonathan Haskins, Facility Case ManagerTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Facility does not provide a safe environment for the residents.
Staff are not adequately trained.
Staff are not qualified.
Staff are not ensuring that the residents don't run out of medications.
Staff are not ensuring that the residents don't run out of food.
Staff are not ensuring that the residents don't run out of supplies.
Staff are not ensuring that the residents receive individual therapy services.
INVESTIGATION FINDINGS:
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***AMENDED REPORT***
On 07/01/2025 at 12:10 PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver amended complaint findings for the allegations above. Upon arrival, LPA met with Johnathan Haskins, Family Case Manager and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with client 1, clients 2 and 3 were not available, Staff 1, 2, 5, 6 and 7. LPA reviewed and received a copy of Client 1 records. LPA toured the facility with Staff 1.

Allegation: Facility does not provide a safe environment for the residents.
Investigation Finding: unsubstantiated.

RP reported that the facility does not have sufficient staff to meet the safety needs of the clients. C1 stated C1 does not feel safe when other clients are having episodes. Record review of LIC 500 shows that there were enough staff on duty for all shifts. Interview with S1 and S2 revealed that facility is fully staffed during all shifts. S1 stated the facility has a safe environment, staff not letting anyone harm anybody. Interview with S2 revealed that the shower doors have locks, the facility is fully staffed and C2 would conduct C2 self-touch in C2 room and never had any contact with C1 Therefore, this allegation is UNSUBSTANTIATED.

Staff are not adequately trained:
Investigation Finding: unsubstantiated.

RP reported that the facility does not have sufficient planned activities. Record review revealed that the facility staff has completed required trainings and in-service training, there was also a calendar showing upcoming trainings. Interview with S2 also revealed that staff are completing trainings yearly. Therefore, this allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
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 6
Control Number 15-AS-20240216091925
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: 03/04/2025
NARRATIVE
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Continue from LIC 9099

Staff are not adequately trained:
Investigation Finding: unsubstantiated.

RP reported that the facility does not have sufficient planned activities. Record review revealed that the facility staff has completed required training's and in-service training, there was also a calendar showing upcoming training's. Interview with S2 also revealed that staff are completing training's yearly. Therefore, this allegation is UNSUBSTANTIATED.


Staff are not qualified:
Investigation Finding: unsubstantiated.

RP reported that the staff are not qualified. Record review revealed that staff have been adequately trained and interview with S2 revealed that staff has training's and in-service training's throughout the year. Therefore, this allegation is UNSUBSTANTIATED

Staff are not ensuring that the residents don't run out of medications.
Investigation Finding: unsubstantiated.

RP stated that staff are not ensuring that the residents don’t run out of medication. Record review of C1 medication administration record (MAR) reveals that C1 refused medications on several occasions. S6 stated that the facility has not been without client medications and C1 often refused to take medication. Therefore, this allegation is UNSUBSTANTIATED

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20240216091925
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: 03/04/2025
NARRATIVE
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continue from LIC 9099A

Staff are not qualified:
Investigation Finding: unsubstantiated.

RP reported that the staff are not qualified. Record review revealed that staff have been adequately trained and interview with S2 revealed that staff has training's and in-service training's throughout the year. Therefore, this allegation is UNSUBSTANTIATED

Staff are not ensuring that the residents don't run out of medications.
Investigation Finding: unsubstantiated.

RP stated that staff are not ensuring that the residents don’t run out of medication. Record review of C1 medication administration record (MAR) reveals that C1 refused medications on several occasions. S6 stated that the facility has not been without client medications and C1 often refused to take medication. Therefore, this allegation is UNSUBSTANTIATED

Staff are not ensuring that the residents don't run out of food.


Investigation Finding: unsubstantiated.

RP stated that staff are not ensuring that the residents don’t run out of food. Tour of facility showed that the pantry was full as well as the refrigerator in the home and in the food and deep freezer storage area were full. Interview with S1 and S2 revealed that grocery shopping is conducted once a week and the facility has a warehouse that’s filled with additional food and hygiene supplies. Therefore, this allegation is UNSUBSTANTIATED

Staff are not ensuring that the residents don't run out of supplies.


Investigation Finding: unsubstantiated.

RP stated that staff are not ensuring that the residents don’t run out of supplies. Tour of the facility showed that the facility has a closet stocked with hygiene supplies. Interview with S1 revealed that if the facility runs low on supplies, they have a warehouse with supplies. Interview with S7 revealed that clients are responsible for their own hygiene supplies, but the facility has supplies if a client is in need. Therefore, this allegation is UNSUBSTANTIATED

Staff are not ensuring that the residents receive individual therapy services.


Investigation Finding: unsubstantiated.

Rp stated that the facility offers group with S3 but the facility dose not have one on one sessions. Interview with S2 revealed that S5 conducts one on one therapy sessions on the weekend. Interview with S5 revealed that S5 conducts one on one sessions at the facility, clients must schedule an appointment. Therefore, this allegation is UNSUBSTANTIATED


Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20240216091925
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: 03/04/2025
NARRATIVE
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CONTINUE FROM LIC 9099

Based on information obtained, the preponderance of evidenced is met, therefore the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20240216091925
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: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
81019(e)
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81019 Criminal Record Clearance (e) All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility:
-This requirement is not met as evidenced by:
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Administrator to read understand regulation and conduct in-service with all parties that handle on boarding of staff. Licensee to provide a sign in sheet of all attendees to the Department by the POC date.
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by allowing staff to work at the facility and not being criminal record cleared or associated to the facility posed a health and safety risk to persons in care.
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 Licensee to work in conjunction with CCL to confirm all care staff have criminal background clearances prior to employment.

penalty will be assessed.
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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: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6