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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320351
Report Date: 05/22/2023
Date Signed: 05/31/2023 02:21:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2023 and conducted by Evaluator Lizeth Villegas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230519122944
FACILITY NAME:KHEMAS RESIDENTIAL HOME 1FACILITY NUMBER:
198320351
ADMINISTRATOR:MOSES, OLAKEMI LEAH-AYOMIFACILITY TYPE:
735
ADDRESS:19214 BELSHAW AVENUETELEPHONE:
(310) 922-0779
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:4CENSUS: 4DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Administrator Olakemi MosesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff relocated clients without consent.
Facility began operating prior to obtaining license.
INVESTIGATION FINDINGS:
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On 5/22/23 Licensing program analyst (LPA) Lizeth Villegas and Licensing program manager (LPM) Janae Hammond initiated a complaint investigation regarding the above allegations, during todays visit we met with Administrator/Licensee Olakemi Moses and the purpose of the visit was explained.
The investigation consisted of the following: On 5/22/23 at around 10:45 am LPA/LPM interviewed Administrator/Licensee Olakemi Moses, interviewed witness #1, toured the physical plant and requested records (staff and client roster and emergency Identification sheet for all four clients)
The investigation revealed the following: Allegation, Facility staff relocated clients without consent licensee moved clients to a new location without receiving consent from clients authorized representatives. On 5/22/23 LPA/LPM interviewed licensee Olakemi Moses, licensee stated that she initiated a change of location from the facilities previous address to the new address and informed the clients authorized representatives verbally. Licensee stated that she followed up with south central Los Angeles regional center after her pre-licensing and received verbal consent to move the clients. Licensee indicated that she moved all clients on May 15,2023. On 5/22/23 LPA/LPM interviewed witness #1 and indicated that South Central Regional Center did not provide consent to move clients to new location.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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 3
Control Number 11-AS-20230519122944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: KHEMAS RESIDENTIAL HOME 1
FACILITY NUMBER: 198320351
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
85072(a)(2)
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In addition to Section 80072, the following shall apply. To have the facility inform his/her relatives and authorized representative, if any, of activities related to his/her care and supervision, including
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Licensee shall obtain consent from clients authorized representatives, licensee shall submit proof of correcting by POC due date.
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but not limited to notification of any modifications to the needs and services plan.
This requirement is not as evidence by:
based on interviews and records review the licensee did not comply with the section cited above by not obtaining consent from clients authorized consent prior to moving clients to new location which poses a personal rights risk to clients in care.
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Type B
06/02/1503
Section Cited
HSC
1503.5
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A facility shall be deemed to be an "unlicensed community care facility" and "maintained and operated to provide nonmedical care..The facility is providing care or supervision, as defined by this chapter or the rules and regulations adopted pursuant to this chapter
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The requirement is not met as evidence by, based on interviews and records review the licensee failed to comply with the section cited above by moving clients on 5/15/23 without lincesee at the adress. this poses a health and safety risk for clients in care.
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Cleared at the time of visit. Facility was linced on 5/17/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230519122944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: KHEMAS RESIDENTIAL HOME 1
FACILITY NUMBER: 198320351
VISIT DATE: 05/22/2023
NARRATIVE
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On 5/22/23 LPA/LPM conducted a file review that revealed the new facility was licensed on May 17,2023. LPA/LPM reviewed facility records and there is no evidence/documentation to support clients authorized representatives provided consent to move clients to new location.

Allegation: Facility began operating prior to obtaining license.

On 5/22/23 LPA/LPM interviewed Administrator/Licensee Olakemi Moses stated that all clients were moved on 5/15/23. LPA/LPM conducted a file review which revealed that the facilities’ new location was licensed on 5/17/23. Based on interview and records review the licensee began operation of new location two days prior to licensure.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 and 6 are being cited on the attached LIC 9099D.



Exit interview was conducted with Administrator/Licensee Olakemi Moses, appeal
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3