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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602858
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:51:30 PM

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
12/24/2020 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201224085313
FACILITY NAME:KOKUMAH EVERYDAY GRACE ONE INCORPORATIONFACILITY NUMBER:
198602858
ADMINISTRATOR:AKINWALE VICTOR ORUNESAJOFACILITY TYPE:
735
ADDRESS:21236 FIBRE COURTTELEPHONE:
(818) 448-3012
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:4CENSUS: 3DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Staff Ben AkinoleTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff hit a client while in care
INVESTIGATION FINDINGS:
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*** This report supersedes report dated 12/31/2020. This report corrects statement from the previous visit. There were no changes to the findings.***

Licensing Program Analyst (LPA) Jose Villalobos initiated a subsequent complaint investigation for the allegations listed above. LPA Villalobos met with Staff Ben Akinole

The investigation consisted of the following: LPA interviewed Client #1 (C1), Client # 2 and #3 were unable to be interviewed due to being under isolation, Client #4 was not in the facility. LPA interviewed Staff #1 (S1) - Staff #3(S3). LPA interviewed Service Coordinator (SC) from C1's placement agency. Incident Report documentation was collected from C1s placement agency

The investigation revealed the following: In regards to the allegation "Staff hit a client while in care", it is alleged that C#1 was hit by staff of the facility...

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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-20201224085313
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: KOKUMAH EVERYDAY GRACE ONE INCORPORATION
FACILITY NUMBER: 198602858
VISIT DATE: 09/30/2021
NARRATIVE
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(3) of (3)Staff interviewed denied the allegation. When LPA interviewed C1, C1 denied the allegation. C1 could not corroborate the allegation. Interview with C1's SC also stated the allegation could not be corroborated. Based on interviews conducted and documents provided to LPA, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2