<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601207
Report Date: 03/23/2022
Date Signed: 05/26/2023 02:04:12 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
03/17/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220317120222
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: 4DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Robert WilliamsTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adult is providing care and supervision to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report to remove confidential name. Findings remain Substantiated and previously issued LIC9099s are rescinded. LPA Glenn Trueman re-delivered reports on 05/26/2023 and obtained signatures.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff S1 and explained the reason for the visit. The purpose of the visit is to investigate the above allegation. Shortly thereafter Administrator Robert Williams II arrived. At 9:15 AM Staff S 1 was interviewed. At 9:45 AM Administrator Robert Williams II was interviewed. In regards to the allegation Uncleared adult is providing care and supervision to residents, based on interviews conducted and information gathered Staff S 1 in interview stated his date of birth which is the same date of birth listed on the Criminal Clearance for the staff that is uncleared. S 1 stated his name was S 2's name which was a staff that was cleared on the clearance list. Administrator confirmed that the staff present at today's visit S 1 is uncleared. Based on LPA's observations, documents review, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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-20220317120222
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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
CCR
80019(e)(1)
1
2
3
4
5
6
7
Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The facility will ensure all staff members are fingerprint cleared and associated prior to working or being present at the facility. The licensee will submit a plan of action on how they will ensure individuals will not be present at the facility until they are cleared by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted it was revealed by the Administrator that Staff S 1 was an uncleared adult and should not have been present at the facility and this caused an Immediate Health and Safety risk to clients in care.
Civil Penalty assessed $500.
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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2