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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601207
Report Date: 10/11/2024
Date Signed: 10/11/2024 09:30:43 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/04/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241004084143
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:
10/11/2024
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Robert WilliamsTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff do not ensure the home has an adequate food supply
Staff do not seek timely medical attention for a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with the Robert Williams (S-1) and discussed the purpose of this visit.

During this visit, LPA interviewed Staff #1 (S-1) and Staff #2 (S-2), interviewed Client #1 (C-1), Client #3 (C-3) and Client #4 (C-4), reviewed C-2’s file and conducted a tour. LPA was unable to interview Client #2 (C-2) as C-2 was not home during this visit and was unreachable.

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

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 28-AS-20241004084143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KINGSLEY HOME CARE
FACILITY NUMBER: 198601207
VISIT DATE: 10/11/2024
NARRATIVE
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Allegation: Staff do not ensure the home has an adequate food supply. It has been alleged that there is not enough food in this home. Staff interviews revealed that the facility has adequate food supply available. Interviewed staff indicated there is additional food supply stored inside the detached garage. Interviewed staff indicated they have not received any complaints/concerns regarding this matter. Client interviews revealed that the facility has adequate food supplies and have no concerns. LPA conducted a tour and observed the food supply. Interviews and tour do not corroborate this allegation.

Allegation: Staff do not seek timely medical attention for a client. It has been alleged that staff are not seeking medical attention for clients in a timely manner. Staff interviews revealed that staff are seeking medical attention for clients in a timely and/or routine manner. Interviewed staff indicated they have not received any requests from any clients in regards to scheduling medical appointments. Interviewed staff indicated they have not received any complaints/concerns regarding this matter. Client interviews revealed that staff seek medical attention for clients in a timely manner and have no concerns. Interviews do not corroborate this allegation.

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

Exit interview conducted, Appeals Rights and a copy of this report was provided to Robert Williams.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
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