198602858-1-9-2023-28-AS-RORN-CPC2C9-20230223161621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602858
Report Date: 01/09/2023
Date Signed: 01/09/2023 02:40:25 PM

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
01/03/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230103170516

FACILITY NAME:	KOKUMAH EVERYDAY GRACE ONE INCORPORATION		FACILITY NUMBER:	198602858
ADMINISTRATOR:	JOHN WILSON		FACILITY TYPE:	735
ADDRESS:	21236 FIBRE COURT		TELEPHONE:	(818) 448-3012
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	4	CENSUS: 4	DATE:	01/09/2023
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	John Wilson - Administrator		TIME COMPLETED:	02:48 PM

ALLEGATION(S):

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Staff yelled at client
Staff did not treat client with dignity or respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez 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-3/Administrator arrived a short time later.

During this investigation, LPA obtained a copy of the Client Roster, a copy of the Staff Roster, interviewed Staff #1 through Staff #5 (S-1 through S-5), interviewed Client #1 and Client #2 (C-1 and C-2).LPA also interviewed witness 1 (W-1) LPA was unable to interview Client #3 (C-3) and Client #4 (C-4) as they are non-verbal. LPA reviewed C1-C3 '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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

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-20230103170516

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: KOKUMAH EVERYDAY GRACE ONE INCORPORATION	FACILITY NUMBER: 198602858
	VISIT DATE: 01/09/2023

NARRATIVE

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...(Continued from 9099)

Allegation: Staff yelled at client. During this investigation, LPA interviewed Staff #1 through Staff #5 (S-1 through S-5), interviewed Client #1 and Client #2 (C-1 and C-2). LPA was unable to interview Client #3 (C3) or client #4 (C4) as C-3 and C-4 are non-verbal. One witness was also interviewed (W-1). Interviewed staff indicated staff are not yelling at clients nor have staff witnessed any staff yelling at clients. Interviewed staff indicated they are trained in Client Rights, Mandated Reporting, Zero Tolerance and Crisis Prevention Intervention (CPI). Interviewed Clients 1/2 stated that one staff yells at clients but indicated they have not observed any staff being mean or mistreating clients. Staff and 1 of 2 clients interviewed did not corroborate this allegation. W1 could not collaborate the allegations.

Allegation: Staff did not treat client with dignity and respect: During this investigation, LPA interviewed Staff #1 through Staff #5 and one witness (S-1 through S-5, (W-1) interviewed Client #1 and Client #2 (C-1 and C-2). LPA was unable to interview Client #3 (C-3) and Client #4 as C-3 and C4 are non-verbal. Interviewed staff 5/5 indicated staff treat clients with dignity and respect and denied allegation. Staff indicated they are trained in Client Rights, Mandated Reporting, Zero Tolerance and Crisis Prevention Intervention (CPI). W1 did not collaborate the allegations. Interviewed Clients 2/2 indicated they have not observed any staff treating clients disrespectful or without dignity. Staff, witness and Client 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 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 Administrator John Wilson-E

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023

LIC9099 (FAS) - (06/04)

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