198320304-5-19-2026-11-AS-SCIS-DUAQY6-20260521123436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320304
Report Date: 05/19/2026
Date Signed: 05/19/2026 12:47:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2026 and conducted by Evaluator Felisa Shirley

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260306103138

FACILITY NAME:	KINAH MAE HOME LLC		FACILITY NUMBER:	198320304
ADMINISTRATOR:	WHITFORD, WALKIRIA		FACILITY TYPE:	740
ADDRESS:	1420 W. 186TH ST.		TELEPHONE:	(310) 720-7080
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY:	6	CENSUS: 3	DATE:	05/19/2026
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Renette De La Cruz, Administrator		TIME COMPLETED:	12:46 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not follow resident’s dietary needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created 3/23/26.

On 3/23/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Marylou Santos, Caregiver and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 3/19/26 LPA Shirley reviewed copies of the following records: Physicians Report, Skin/Body Check dated 1/7/26, Incident reports for 1/7/26 and 1/29/26, and picture of wheelchair ramp in living room, screenshot of conversation dated 1/21/26. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 4(S1 – S4), and Resident -1 – Resident - 6(R1-R6). R1 an R6 did not respond to questions.

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

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 7

Control Number 11-AS-20260306103138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
	VISIT DATE: 05/19/2026

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

The investigation revealed the following:

Allegation: Staff did not follow resident’s dietary needs

It is being reported that R1 is lactose intolerant and staff were not aware as staff were giving him dairy products. On 5/19/26, LPA Felisa Shirley reviewed R1’s Admission Agreement, dated 9/28/29, states in the Food Services section, Special diets if prescribed by a doctor. LPA Shirley reviewed R1’s Physician Report dated, 12/16/25, stating that R1’s special diet was to limit dairy, limit ice cream, (ok once in a while). On 5/19/26, LPA Shirley observed a text message to a family member from S1 on 1/21/26, advising them that she purchased almond milk for R1 and the family member responded back saying the purchase was fine and thanked S1 for buying this for R1. On 3/23/26, LPA Felisa Shirley observed the special diets for residents R3 and R4 posted on the refrigerator. Per interview with S4 on 3/23/26, R1’s special diet was posted on the refrigerator during his stay at Kinah Mae Home, LLC. During file review, LPA Shirley did not observe instructions to staff regarding the special diet of R1. On 5/19/26, LPA Shirley interviewed S1 and S4 regarding the special diet of R1. Both staff acknowledged that R1’s special diet was no diary. During interviews, S4 stated that she was told by R1’s family member to give him water every 20 minutes. On 5/19/26, LPA Shirley did not observe R1’s special diet posted on the refrigerator as he has not been at this facility since 1/29/26.

LPA interviewed staff 1 – staff 4(S-1 – S-3). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 1 out of 6 denied the allegation. Three residents were not on special diets and 2 residents did not respond.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not follow resident’s dietary needs,” therefore, the allegation is unsubstantiated.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2026 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20260306103138

FACILITY NAME:	KINAH MAE HOME LLC		FACILITY NUMBER:	198320304
ADMINISTRATOR:	WHITFORD, WALKIRIA		FACILITY TYPE:	740
ADDRESS:	1420 W. 186TH ST.		TELEPHONE:	(310) 720-7080
CITY:	GARDENA	STATE: CA	ZIP CODE:	90248
CAPACITY:	6	CENSUS:	DATE:	05/19/2026
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Renette De La Cruz, Administrator		TIME COMPLETED:	12:46 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not ensure resident received medical care in a timely manner
Staff do not follow reporting requirements
Staff do not ensure the facility is free of hazards

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 11-AS-20260306103138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
	VISIT DATE: 05/19/2026

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

Allegation: Staff did not ensure resident received medical care in a timely manner

It is being reported that the facility staff failed to notify the family that R1 had a fall during the night of 1/6/26 and failed to seek medical treatment. Per interview with a family member of R1, during a visit on 1/8/26 the facility staff informed them that R1 had bruises and a skin tear on his right arm and they didn’t know how it happened. Per the family member the skin tear was already beginning to scab. On 3/19/26, LPA Shirley observed a Skin/Body Check form completed by S1 on 1/7/26 indicating an abrasion with mild pain and light bleeding on R1’s right arm. The family member took R1 to urgent care to be assessed on 1/9/26. Per review of an incident report dated 2/2/26, R1 tripped and fell in the facility on 1/29/26. Staff rendered first aid and called his designated emergency contact. On 5/19/26, S1 stated that R1 seemed to be stable and was still mobile following the fall so emergency services where not called. Due to the nature of the fall and assessment the family member called 911 when she arrived at the facility. When the paramedics arrived, they conducted an assessment which warranted a transfer to Kaiser for further diagnostic evaluation and ongoing medical care. After R1 was discharged from the hospital he did not return to Kinah Mae Home, LLC.

LPA interviewed staff 1 – staff 4(S-1 – S-4). Of those interviewed 4 out of 4 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. Two residents did not respond.

Based on interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Allegation: Staff do not follow reporting requirements

It is being reported that the facility staff failed to notify the family that R1 had a fall the night of 1/6/26. Per interview on 3/10/26, the facility administrator, S1 stated that R1 had an incident on 1/7/26, but she did not know that she was supposed to report the fall to Community Care Licensing Division, (CCLD). Per S1 she did not complete nor submit an incident report to CCLD. LPA Shirley advised S1 to complete an incident report and report the incident to CCLD right away. On 3/19/26, S1 sent a picture of a notice of an incident to LPA Shirley by text message advising of an incident involving R1 that occurred on 1/7/26 at 2am.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 11-AS-20260306103138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
	VISIT DATE: 05/19/2026

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 interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Allegation: Staff do not ensure the facility is free of hazards

It is being reported that the wheelchair ramp located in the living room of this facility is dangerous and a tripping hazard. On 3/19/26, LPA Shirley reviewed a notice of an incident dated 2/2/26, advising of an incident involving R1 tripping and falling within the facility that occurred on 1/29/26. LPA Shirley has been to this facility previously for required annuals/inspections and observed the wheelchair ramp without the handrail. On 3/10/26, LPA Shirley observed that there was a handrail installed along the right side of the wheelchair ramp. Per interview with S-4, the handrail was installed after the trip and fall of R1.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 11-AS-20260306103138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/06/2026 Section Cited CCR 80075(a)	1 2 3 4 5 6 7	80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not as evidenced by:	1 2 3 4 5 6 7	The Administrator shall review regulation and train all staff on getting timely medical services for residents in care. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.
	8 9 10 11 12 13 14	Based on interviews and a review of Skin/Body Check form, staff did not seek timely medical care for R1. This poses a potential personal rights violation to persons in care.	8 9 10 11 12 13 14
Type B 04/06/2026 Section Cited CCR 87211(a)(11)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (11) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not as evidenced by:	1 2 3 4 5 6 7	The Administrator shall review regulation and train all staff on proper reporting of incident involving residents. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.
	8 9 10 11 12 13 14	Based on interviews and a review of a notice of an incident letter, staff did report incident to responsible party nor Community Care Licensing, (CCLD). This poses a potential personal rights violation 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 11-AS-20260306103138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINAH MAE HOME LLC	FACILITY NUMBER: 198320304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/06/2026 Section Cited CCR 87307(d)(4)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not as evidenced by:	1 2 3 4 5 6 7	The Administrator shall review regulation and train all staff on creating reasonably safe conditions and environments for residents in care. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 4/6/26, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.
	8 9 10 11 12 13 14	Based on interviews and a review of a notice of an incident letter, facility staff failed to provide a safe environment for residents in care. This poses a potential personal rights violation to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 7