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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602916
Report Date: 02/08/2024
Date Signed: 02/08/2024 03:46:38 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
06/08/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230608150716
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:
02/08/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rafael Menendez - LicenseeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff caused an injury to resident.
Staff engaged in physical altercation with resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted a subsequent complaint investigation visit regarding the allegations above. LPA met with Rafael Menendez (Licensee) and explained the purpose of the visit.

The investigation consisted of the following: On 06/09/2023, LPA Mora requested copies of client and staff rosters, and file documents for Client 1 (C1). LPA conducted a tour of the facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. During today's visit, LPA interviewed Administrator, Staff 1 - Staff 3 (S1 - S3), Client 1 - Client 4 (C1 - C4), and Regional Center Service Coordinator.

The investigation revealed the following: in regard to the allegations "staff caused an injury to resident" and
"staff engaged in physical altercation with resident", it is alleged that C1 had mild discoloration on the right eye caused by a fight with a staff. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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-20230608150716
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: CASA KLINEDALE
FACILITY NUMBER: 198602916
VISIT DATE: 02/08/2024
NARRATIVE
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Administrator and staff denied the allegation. They stated that C1's story changed because at first C1 accused a staff from this facility and then a client from the day program. C1 refused to be interviewed. C2 could not corroborate the allegation and stated that none of the staff at this facility have gotten physical with any of the clients. C3 and C4 are non-verbal and were unable to answer the LPA's questions. Regional Center Service Coordinator stated that Regional Center conducted their own investigation which resulted in no findings.

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.

Exit interview conducted, and a copy of report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2