107209095-5-2-2023-24-AS-SPIY-CURRNJ-20230816131026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209095
Report Date: 05/02/2023
Date Signed: 05/02/2023 04:11:26 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, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2023 and conducted by Evaluator Katie Brown

COMPLAINT CONTROL NUMBER: 24-AS-20230428155644

FACILITY NAME:	KAREN'S HOUSE II		FACILITY NUMBER:	107209095
ADMINISTRATOR:	JACOBS, TEMIKA TRINA		FACILITY TYPE:	735
ADDRESS:	4753 W. MENLO AVE		TELEPHONE:	(559) 275-3277
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	3	CENSUS: 3	DATE:	05/02/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Temika "Kym" Jacobs		TIME COMPLETED:	03:31 PM

ALLEGATION(S):

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Facility staff threatened resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial 10-Day complaint investigation. LPA met with and explained the reason for the visit with Administrator (AD) Kym Jacobs.

During the visit, LPA interviewed AD and R1. Interviews revealed conflicting information as to the evernts that occured. Record review of R1's Individualized Program Plan (IPP) states that R1 has a history of fabricating incidents when R1 is upset. R1 received a 30 day eviction notice and has demonstrated increased aggitation and disruptive behaviors. Based on interviews and record review, the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

There were no citations issued

An exit interview was conducted and a copy of this report was emailed to AD during the visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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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