<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602916
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:09:05 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
09/27/2021 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210927093026
FACILITY NAME:CASA KLINEDALEFACILITY NUMBER:
198602916
ADMINISTRATOR:MENENDEZ, SAMIRAFACILITY TYPE:
735
ADDRESS:9243 KLINEDALE AVENUETELEPHONE:
(562) 440-7531
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY:4CENSUS: 4DATE:
02/18/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Samira Menendez - AdministratorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not provide adequate supervision to a client while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Luis Mora conducted a subsequent visit to deliver complaint investigation findings. LPA met with Administrator Samira Menendez and explained the purpose of the visit.

The investigation consisted of the following: On 10/05/2021, LPA conducted an initial complaint investigation visit, obtained client and staff rosters, interviewed the Administrator and Staff #1 through Staff #3 (S1-S3), obtained Client #1 (C1) Regional Center Coordinator contact info, reviewed C1 file and requested copies of face sheet, preplacement appraisal information, functional capability assessment, independent consulting services, and Individual Program Plan (IPP). On 10/07/2021, LPA conducted a telephone interview with C1’s Regional Center Coordinator (RCC). On today’s visit, LPA conducted interviews with Client #1 through Client #4 (C1 – C4) and C1’s family member (C1FM), and obtained a copy of C1's Physician Report.

The investigation revealed the following: in regard to the allegation "staff does not provide adequate supervision to a client while in care", it is alleged that C1 has been seen walking in the neighborhood alone and may have some special needs that require adequate supervision. (CONTINUED TO LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
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-20210927093026
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: CASA KLINEDALE
FACILITY NUMBER: 198602916
VISIT DATE: 02/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on interviews conducted and records reviewed, C1 can leave the facility without supervision and is receiving adequate supervision and care from staff at the facility.

The facility’s licensure status was also questioned. Based on records review, this facility is licensed to serve 4 ambulatory clients only in the age range of 18 through 59. The facility’s license has an effective date of 03/29/2019.

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

No deficiencies were cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2