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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601207
Report Date: 07/08/2022
Date Signed: 07/08/2022 10:18:37 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
11/02/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211102114246
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:
09:00 AM
MET WITH:Facility AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff spoke inappropriately to client.
INVESTIGATION FINDINGS:
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On 11/10/2021, Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with the Facility Administrator and discussed the purpose of this visit. During this visit, LPA interviewed Staff #1 (S-1) and interviewed Client #1 through Client #3 (C-3). Client #4 (C-4) was not home during this visit (does not have a cell phone to conduct a telephone interview). Staff #2 (S-2) was not present during today's visit. LPA obtained S-2's contact information for interview purposes. LPA also requested pertinent documentation.

During this investigation, at a later time, LPA also interviewed Staff #2 (S-2). LPA was unable to interview Client #4 (C-4) as C-4 was unable to understand the interview questions.

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-20211102114246
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
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Allegation: Staff spoke inappropriately to client. During this investigation, LPA interviewed C-1 through C-3. LPA was unable to interview C-4 as C-4 was unable to understand the interview questions. LPA also interviewed S-1 and S-2. (1) out of (3) interviewed clients, indicated S-1 spoke inappropriately (using profanity/foul language) to C-2. (2) out of (3) interviewed clients indicated staff do not speak to clients inappropriately. Staff interviews revealed that staff do not speak to clients inappropriately. Client and Staff 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: 2 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
11/02/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211102114246

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:
09:00 AM
MET WITH:Facility AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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9
Staff handled client in a rough manner.
Staff inappropriately restrained client.
INVESTIGATION FINDINGS:
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On 11/10/2021, Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with the Facility Administrator and discussed the purpose of this visit. During this visit, LPA interviewed Staff #1 (S-1) and interviewed Client #1 through Client #3 (C-3). Client #4 (C-4) was not home during this visit (does not have a cell phone to conduct a telephone interview). Staff #2 (S-2) was not present during today's visit. LPA obtained S-2's contact information for interview purposes. LPA also requested pertinent documentation.

During this investigation, at a later time, LPA also interviewed Staff #2 (S-2). LPA was unable to interview Client #4 (C-4) as C-4 was unable to understand the interview questions.

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: 3 of 5
Control Number 28-AS-20211102114246
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
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Allegation: Staff handled client in a rough manner. During this investigation, LPA interviewed C-1 through C-3. LPA was unable to interview C-4 as C-4 was unable to understand the interview questions. LPA also interviewed S-1 and S-2. (1) out of (3) interviewed clients, indicated S-1 held C-2 on the ground (laying flat on the stomach with the arms facing forward and C-2’s sweater hoodie covering C-2’s face) due to C-2’s behavior. (1) out of (2) interviewed staff, indicated S-1 followed C-2 to the front yard of this facility and attempted to redirect C-2 as C-2 was displaying inappropriate behaviors including property destruction. During the attempted redirection, per S-1 interview, C-2 picked up a large rock and threw it in the direction of S-1. S-1 admitted to placing a “brief” restraint due to C-2’s physical aggression (including C-2 attempting to bite S-1) by placing S-1’s knees on C-2's back, pinned C-2 with C-2's arms stretched out. S-1 handled C-2 in a rough manner. Based on Staff interview, this allegation is corroborated.

Allegation: Staff inappropriately restrained client. During this investigation, LPA interviewed C-1 through C-3. LPA was unable to interview C-4 as C-4 was unable to understand the interview questions. LPA also interviewed S-1 and S-2. (1) out of (3) interviewed clients, indicated S-1 held C-2 on the ground (laying flat on the stomach with the arms facing forward and C-2’s sweater hoodie covering C-2’s face) due to C-2’s behavior. (1) out of (2) interviewed staff, indicated S-1 followed C-2 to the front yard of this facility and attempted to redirect C-2 as C-2 was displaying inappropriate behaviors including property destruction. During the attempted redirection, per S-1 interview, C-2 picked up a large rock and threw it in the direction of S-1. S-1 admitted to placing a “brief” restraint due to C-2’s physical aggression (including C-2 attempting to bite S-1) by placing S-1’s knees on C-2's back, pinned C-2 with C-2's arms stretched out. S-1 inappropriately restrained client. Based on Staff interview, this allegation is corroborated.

The preponderance of evidence standard has been met, therefore the above allegations are 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: 5 of 5
Control Number 28-AS-20211102114246
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
80072(a)(3)
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Personal Rights-Except for children’s residential facilities, 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, including but not
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The Licensee, administrator, and staff shall review title 22 regulations pertaining to personal rights and attend an in-service training.
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limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This standard is not met as evidence by:
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Licensee and/or Administrator to submit proof of in-service training which shall include: name of participant with signature, date, duration of training and curriculum used for personal rights training to LPA by POC due date of 07/15/2022.
Type B
07/15/2022
Section Cited
CCR
80072(a)(3)
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THIS IS A CONTINUATION OF PERSONAL RIGHTS CITED ABOVE.

S-1 admitted to placing a “brief” restraint due to C-2’s physical aggression (including C-2 attempting to bite S-1) by placing S-1’s knees on C-2's back, pinned C-2 with C-2's arms stretched out.
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S-1 handled C-2 in a rough manner and inappropriately restrained C-2.
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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: 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: 4 of 5