198320304-2-25-2026-11-AS-SCIS-DUAN6E-20260521101053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320304
Report Date: 02/25/2026
Date Signed: 02/25/2026 03:09:12 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
02/20/2026 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20260220083424

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: 5	DATE:	02/25/2026
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Renette DeLaCruz, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not provide adequate supervision, resulting in residents falling.
Staff did not communicate with residents authorized representative.
Staff do not respond to residents call bells in a timely manner.

INVESTIGATION FINDINGS:

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On 2/25/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Renette De La Cruz 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 2/25/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information form, Physicians Report and an Incident report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3 (S1 – S3), and Resident -1 – Resident - 5(R1-R5).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

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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Control Number 11-AS-20260220083424

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: 02/25/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Staff do not provide adequate supervision, resulting in residents falling.

It is being reported that a former resident fell and staff did not report to the resident’s family right away. On 2/25/26, LPA Felisa Shirley reviewed a letter to Community Care Licensing Department, CCLD, LPM Stephanie Cifuentes dated 2/2/26, reporting a fall by a former resident in which staff treated the resident and called the resident’s emergency contact. Per interview with the facility Administrator, 2/25/26, she sent letter to LPA Shirley’s manager as she did not have the correct contact for LPA Shirley.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not provide adequate supervision, resulting in residents falling,” therefore, the allegation is unsubstantiated.

Allegation: Staff did not communicate with residents authorized representative.

It is being reported that R1 fell out of the bed several times and these incidents were never reported to the resident’s emergency contact person. On 2/25/26, LPA Shirley requested the incident reports for the prior 6 months. The Administrator submitted a report, but it was not for the resident in question. Per interview, 2/25/26, the Administrator never submitted an incident report for R1 as there were no reports of R1 falling.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not communicate with residents authorized representative,” therefore, the allegation is unsubstantiated.

Con'd 0n 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20260220083424

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: 02/25/2026

NARRATIVE

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Allegation: Staff do not respond to residents call bells in a timely manner.

It is being reported that R1 called a family member to report that he needed assistance in the facility and the staff weren’t responding when he pressed the call bell. Per interview, 2/25/26, S3 stated if the direct lines to the facility go unanswered, families sometimes utilize personal contact numbers of the staff, and staff return calls at their earliest convenience. Per interview, 2/25/26, R4 stated at times the staff informs her they are working with another resident. I understand that I’m not the only one that needs assistance, and I’m happy to wait. I don’t have to wait too long.

LPA interviewed staff 1 – staff 3(S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 3 out of 5 denied the allegation. Two Residents confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not respond to residents call bells in a timely manner,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Renette DeLaCruz.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2026

LIC9099 (FAS) - (06/04)

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