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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602858
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:06:46 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
02/01/2022 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220201103210
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:
02/09/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:S-1 and S-4TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are mistreating a client while in care.
Staff hit a client while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegations. LPA met with S-1 and discussed the purpose of today's visit. S-4/Administrator arrived at approximately 10:10 A.M..

During this investigation, LPA obtained a copy of the Client Roster, a copy of the Staff Roster, interviewed Staff #1 through Staff #4 (S-1 through S-4), interviewed Client #1 and Client #2 (C-1 and C-2). LPA was unable to interview Client #3 (C-3) as C-3 is non-verbal. LPA reviewed C-1's file and obtained relevant documentation.

Refer to LIC 9099C for the contination 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: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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-20220201103210
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: 02/09/2022
NARRATIVE
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Allegation: Staff are mistreating a client while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4), interviewed Client #1 and Client #2 (C-1 and C-2). LPA was unable to interview Client #3 (C-3) as C-3 is non-verbal. Interviewed staff indicated staff are not mistreating clients at home nor have staff witnessed anyone mistreating clients. Interviewed staff indicated staff are not mean to clients. Interviewed staff indicated they are trained in Client Rights, Mandated Reporting, Zero Tolerance and Crisis Prevention Intervention (CPI). Interviewed Clients indicated staff do not mistreat clients and that staff are not mean towards clients. Interviewed Clients indicated they have not observed any staff being mean or mistreating clients. Staff and Client interviews do no corroborate this allegation.

Allegation: Staff hit a client while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4), interviewed Client #1 and Client #2 (C-1 and C-2). LPA was unable to interview Client #3 (C-3) as C-3 is non-verbal. Interviewed staff indicated staff do not hit clients nor have staff witnessed anyone hitting clients. Interviewed staff indicated they are trained in Client Rights, Mandated Reporting, Zero Tolerance and Crisis Prevention Intervention (CPI). Interviewed Clients indicated they have not observed any staff hitting clients. Staff and Client interviews do no corroborate this 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, a copy of this report and Appeal Rights were provided to S-4

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2