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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602858
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:45:35 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
05/09/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240509164420
FACILITY NAME:KOKUMAH EVERYDAY GRACE ONE INCORPORATIONFACILITY NUMBER:
198602858
ADMINISTRATOR:JOHN WILSONFACILITY TYPE:
735
ADDRESS:21236 FIBRE COURTTELEPHONE:
(818) 448-3012
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:4CENSUS: 4DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Olu Odofin, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff verbally abuse client in care.
Staff harass client in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegations listed above. LPA arrived unannounced and met with Administrator, Oluwagbemiro Odofin. The purpose of the visit was explained.

LPA toured the facility. The staff and client rosters were obtained. LPA reviewed clients files and staff training logs. Interviews were held with the licensee, administrator, and 5 Staff. LPA was unable to interview Clients #1 (C-1) and #2 (C-2) as they are non-verbal. The other 2 clients were not home during the visit.

The investigation revealed the following:
Allegation – Staff verbally abuse client in care. It is alleged that a staff member tells Client #1 (C-1) to shut up daily. The licensee and administrator stated they were not aware of any abuse until the police officer arrived at the facility on 5/9/24.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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-20240509164420
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: 05/16/2024
NARRATIVE
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The officer interviewed clients and concluded there were no signs of any abuse. Administrator also stated that the Quality Assurance Specialist from the San Gabriel/Pomona Regional Center also showed up on the same day to conduct their investigation. LPA interviewed additional 5 staff. They all stated they have not seen any form of abuse at the home. The staff do not raise their voices or tell clients to shut up when they are displaying a behavior. Instead, staff will attempt to calm down the individual by verbally redirecting them. They stated they receive training on the client rights and zero tolerance policy. If they observe any abuse, they stated they will report right away.

Allegation – Staff harass client in care. It is alleged that a staff taps Client #1 (C-1) on the head after dinner daily. LPA interviewed the licensee, administrator and 5 staff. The administrator has not heard of any staff harassing the client(s). Administrator stated the police officer and the San Gabriel/Pomona Quality Assurance Specialist visited the facility due to the accusation. They checked C-1 and did not observe any injuries or marks to the body. Staff stated they receive consumer rights training and treat the clients respectfully. They assist them with their needs and provide a comfortable living environment. They are aware of clients’ behaviors and know how to prevent it from happening or escalating. Staff do not do things to provoke a client or get them to comply.

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.



An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2