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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601207
Report Date: 07/08/2022
Date Signed: 07/08/2022 10:20:37 AM

Unsubstantiated


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
03/08/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220308142907
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:
07/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Facility AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client's rights to smoke were violated.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial investigation on 03/14/2022.

During the course of this investigation, LPA interviewed Staff #1, Staff #2 (S-1 and S-2), Client #3 (C-3) and Client #4 (C-4). LPA attempted to interview Client #1 and Client #2 (C-1 and C-2), however, C-1 and C-2 were unable to understand the interview questions. LPA also reviewed C-3's file and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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 5
Control Number 28-AS-20220308142907
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
VISIT DATE: 07/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Client's rights to smoke were violated. During the course of this investigation, LPA interviewed Staff #1, Staff #2 (S-1 and S-2), Client #3 (C-3) and Client #4 (C-4). LPA attempted to interview Client #1 and Client #2 (C-1 and C-2), however, C-1 and C-2 were unable to understand the interview questions. Staff interviews revealed that clients are able to smoke outside either in the front porch or in the backyard. Interviewed staff have not denied Clients the right to smoke. Interviewed Staff indicated they have not received any complaints nor concerns in regards to clients smoking. Client interviews revealed that they are allowed to smoke outside in the from porch or in the backyard. Client interviews revealed that their right to smoke has not been violated. Staff and Client interviews do not corroborate this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated

Exit interview conducted, Appeals Rights and a copy of this report was provided to Facility Administrator.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
03/08/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220308142907

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: DATE:
07/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Facility AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is using unapproved surveillance systems on residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial investigation on 03/14/2022.

During the course of this investigation, LPA interviewed Staff #1, Staff #2 (S-1 and S-2), Client #3 (C-3) and Client #4 (C-4). LPA attempted to interview Client #1 and Client #2 (C-1 and C-2), however, C-1 and C-2 were unable to understand the interview questions. LPA also reviewed C-3's file and obtained relevant documentation.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220308142907
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
VISIT DATE: 07/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility is using unapproved surveillance systems on residents in care. During the course of this investigation, LPA interviewed Staff #1, Staff #2 (S-1 and S-2), Client #3 (C-3) and Client #4 (C-4). LPA attempted to interview Client #1 and Client #2 (C-1 and C-2), however, C-1 and C-2 were unable to understand the interview questions. Staff interviews revealed there are surveillance cameras inside the common areas of this facility. Facility Administrator was unable to locate any documentation that has been submitted to Community Care Licensing pertaining to a surveillance system. Facility Administrator indicated that the surveillance cameras were taken down shortly after a visit that was completed by their Placement Agency. Per Staff interviews, the surveillance cameras do not have audio. Interviewed Clients indicated this facility had surveillance cameras in the common areas only.

The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 & 6 are being cited on the attached LIC 9099D.

Exit interview conducted, Appeal Rights and a copy of this report was provided to Facility Administrator.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220308142907
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: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
80022(j)
1
2
3
4
5
6
7
Plan Of Operation: (j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval. This standard is not met as evidence by: Facility Administrator was unable to locate any documentation that has been submitted to Community Care Licensing pertaining to a surveillance system.
1
2
3
4
5
6
7
Administrator to submit to LPA by 07/15/2022 an updated Plan of Operation (addendum) for having video surveillance cameras in the facility. Licensee must note in the Plan of Operation how the video surveillance records will be maintained and grant CCL staff availability.
8
9
10
11
12
13
14
8
9
10
11
12
13
14
If the records are stored outside of the facility the Licensee must comply with confidentiality laws. Plan to also indicate the specific locations of the cameras and visual/audio features.
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: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5