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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601207
Report Date: 02/24/2022
Date Signed: 02/02/2024 02:46:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2022 and conducted by Evaluator Nune Margaryan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220218101352
FACILITY NAME:KINGSLEY HOME CAREFACILITY NUMBER:
198601207
ADMINISTRATOR:ROBERT WILLIAMS IIFACILITY TYPE:
735
ADDRESS:635 E KINGSLEY AVETELEPHONE:
(909) 524-9446
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:6CENSUS: 3DATE:
02/24/2022
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Robert WilliamsTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff hit a client while in care
INVESTIGATION FINDINGS:
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This is an amended copy of the LIC9099 previously issued on 02/24/22. Previously issued LIC9099 and LIC9099D are rescinded. The purpose of amendment was to remove confidential information. LPA Vaid Sanjay re-delivered reports on 02/02/24 to obtain signatures. The findings remain Substantiated and signatures for amended reports are on hard copies.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint visit to the facility to investigate the above noted allegation. LPA met the Administrator and explained the purpose of the visit. It was alleged that the Staff #1 (S1) "punched" the Client #1 (C1). To investigate the allegation, at 1:45 pm LPA Margaryan spoke with Staff #3 (S3) who indicated that he witnessed the incident between S1 and C1. S1 accidentally "punched" C1 when S1 defended himself/herself from C1 and S3 had to pull S1 away from C1. S1 immediately was removed from the facility and was suspended. At 2:20 pm LPA spoke with C1, who verified the statement provided by the S3 and C1 stated he/she refused to go to urgent care. C1 stated that he/she was not in pain. At 3:20 pm LPA spoke with Staff #2 (S2). At the time of this visit, at 3:40 pm LPA Margaryan reviewed an incident report submitted to the Licensing Office, which revealed the same information provided by S3 and C1. The information revealed from the interviews and record review, verifies the allegation. Therefore, the allegation is Substantiated at this time.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
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 2
Control Number 28-AS-20220218101352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2022
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a)…. Each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature…This requirement is not met as evidenced by:
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This citation was cleared during this visit as the Administrator immediately suspended the staff #1 (S1). Licensee shall ensure by providing a plan/training/statement
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Licensee did not comply with the regulations above. Staff #1 had physical altercation with client. This poses a potential personal rights violation to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2