198320351-1-15-2025-11-AS-JHAD-DD7QCB-20250123110254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320351
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:31:44 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
01/09/2025 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250109105836

FACILITY NAME:	KHEMAS RESIDENTIAL HOME 1		FACILITY NUMBER:	198320351
ADMINISTRATOR:	MOSES, OLAKEMI LEAH-AYOMI		FACILITY TYPE:	735
ADDRESS:	19214 BELSHAW AVENUE		TELEPHONE:	(310) 922-0779
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	4	CENSUS: 4	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Olakemi Moses		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff administered a felony drug to resident.

INVESTIGATION FINDINGS:

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On 1/10/25, at 09:00am, Community Care Licensing Division (CCLD) Staff conducted an initial complaint visit to the facility and was greeted by Olakemi Moses, Administrator. CCLD staff explained the purpose of this visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above.

The investigation consisted of the following: An initial complaint visit was completed by (CCLD) staff on 01/10/2025. A subsequent visit was completed by (CCLD) staff on 01/15/2025. The department investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1) from 09:00am-12:00pm. C1 could not be interviewed because C1 is currently hospitalized.

The department received the following: Client Roster (Dated: 01/25/2023), Staff Roster (Dated: 2025), ID/Emergency Information (Dated: No Date), Physicians Report (Dated: 02/22/2024), Admission Agreement (Dated: 05/03/2022), Medication Administration Records (Dated: 11/01/2024-01/08/2025), Staff In-Service Trainings (Dated: 01/08/2024-09/27/2024)......

Complaint Investigation Report Continued On LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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-20250109105836

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: KHEMAS RESIDENTIAL HOME 1	FACILITY NUMBER: 198320351
	VISIT DATE: 01/15/2025

NARRATIVE

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Physician Order/Medication (Dated: 11/2024), Admission Head to Toe (Dated: No Date) South Central Los Angeles Regional Center Individual Program Plan (Dated: 07/12/2024), Medical Records (Dated: 01/07/2025, 12/26/2024, 12/06/2024, 12/05/2024), and an Unusual Incident Report (Dated: 01/07/2025), from the facility.

The investigation revealed the following: Allegation-Staff administered a felony drug to resident.

The details of the complaint alleged that the staff gave a felony drug to the client (C1). Records reviewed indicated that the client was hospitalized due to dizziness, looking pale, diarrhea, and unable to stand. Subsequent tests showed the client tested positive for Covid, Fentanyl, and Amphetamines. On 1/10/25, from 9:00am-12:00pm, the department interviewed staff (S1) regarding the allegation. C1 could not be interviewed because C1 is currently hospitalized. S1 denied the allegation that the Staff administered a felony drug to resident. Staff (S1) stated that the facility has never given a felony drug to the client (C1) or anyone else. S1 stated that on 01/07/2025 C1 was dropped off by the day program and C1 had feces all over C1s clothes because of uncontrollable diarrhea. S1 stated that S1 gave C1 a shower and took C1 to the hospital because C1 looked pale, weak, and unable to stand.

The hospital admitted C1 because of C1s symptoms, according to S1. S1 stated that subsequently, the hospital notified S1 that C1 had tested positive for Covid, and the drugs Fentanyl and Amphetamines. S1 stated that S1 did not know how C1 could have tested positive for those drugs because C1 is not a drug user, and the facility has not given any of those drugs to C1.

The Department reviewed the Unusual Incident/Injury Report (Dated: 1/07/25) about the hospitalization. The department also reviewed recent Medical Records for C1 (Dated: 01/07/2025, 12/26/2024, 12/06/2024, 12/05/2024) and the Medication Administration Records (Dated: 11/012024-01/08/2025). Medical Record (Dated: 01/07/25) on page 6 of 13 under Inpatient Progress Note, states that high suspicion of false positive tests due to patients Trazadone and Fanapt medication, per literature search. Additionally, the department reviewed the Medication Administration records and did not find any discrepancies. Further, the department received a follow up email from social worker at Harbor UCLA Medical Center stating that the hospitalist confirmed a false positive based on medication after further review.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff administered a felony drug to resident. 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.

No citations were issued.

An exit interview was conducted with Olakemi Moses, Administrator, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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