198603289-5-8-2026-28-AS-DSIS-DU8P7G-20260519110357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603289
Report Date: 05/08/2026
Date Signed: 05/08/2026 12:55:39 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
04/30/2026 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260430120336

FACILITY NAME:	KAISER BEHAVIORAL CENTER WEST COVINA		FACILITY NUMBER:	198603289
ADMINISTRATOR:	JANET DE LUNA		FACILITY TYPE:	775
ADDRESS:	1532 AMAR ROAD STE B		TELEPHONE:	(626) 945-0790
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	75	CENSUS: 42	DATE:	05/08/2026
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Carmela Valadez - Program Manager		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not prevent a client from threatening other clients
Staff are falsifying documents
Staff inappropriately took pictures of clients
Staff inappropriately shared pictures of clients
Staff are not meeting clients needs resulting in injuries
Staff did not prevent a client from wandering from the facility
Staff force clients to participate in activities
Staff did not prevent clients from having access to smoking items

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent unannounced complaint investigation regarding the above allegations. LPA met with Program Manager Carmela Valadez and explained the purpose of the visit.

The investigation consisted of the following:

On 5/7/26 LPA conducted the initial visit, obtained a copy of the staff/client roster and conducted interviews with 5 Staff (S1-S5).
During todays visit LPA obtained a copies Special Incident Report (SIR) and ISP Data Collection, conducted interviews with 5 Clients (C1-C5) and delivered findings on the reported allegations.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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-20260430120336

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: KAISER BEHAVIORAL CENTER WEST COVINA	FACILITY NUMBER: 198603289
	VISIT DATE: 05/08/2026

NARRATIVE

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The investigation revealed the following:
Allegation: Staff did not prevent a client from threatening other clients
It is alleged that facility staff have failed to address a client who threatens to stab or hit staff and other clients with a pen, backpacks, and water bottles. LPA interviewed 5 staff and each denied the allegation, staff stated that the facility is a behavioral program and although this may have happened as clients exhibit behaviors, the behaviors are addressed, documented, and meetings with the behaviorist, the clients service coordinator and facility staff are conducted to develop a plan on how to decrease these behaviors. LPA interviewed 5 clients and each denied the allegation, C1-C4 shared that they have either been hit/pushed by another client or a client has attempted to hit/push them but staff separate that client from the group and talk to them privately. Each client stated they feel safe at the facility.
Allegation: Staff are falsifying documents
It is alleged that S2 and S3 falsify documents and SIR’s (mostly regarding injuries) to protect other staff. LPA interviewed 5 staff and each denied the allegation. Interview with S2 revealed that when SIR’s are created, information from both the ISP Data Collection (information documented by staff that witnessed the incident) and statements provided during investigation are what is documented on the reports. LPA reviewed SIR’s and ISP Data Collection, the information documented appeared to be correct and not missing any information.
Allegation: Staff inappropriately took pictures of clients
It is alleged that S4 has taken inappropriate pictures of clients. LPA interviewed 5 staff and each denied the allegation, staff stated that the only time they take photos of clients is either during intake/admission for their Face Sheet or when an injury is observed, staff stated that these photos are for documentation only and none of the photos are inappropriate. Staff also stated that clients are asked for permission prior to taking their photo. S4 denied the allegation and stated that they have only taken photos for clients face sheets or injuries, photos of injuries will accompany a body mark form to explain the injury. LPA interviewed 5 clients and each denied the allegation, each client stated they are asked if its ok to be photographed, they don’t mind and that the pictures are not inappropriate.
Allegation: Staff inappropriately shared pictures of clients
It is alleged that S4 has sent inappropriate pictures of clients to old managers. LPA interviewed 5 staff and each denied the allegation, staff stated that the only time they take photos of clients is either during intake/admission for their Face Sheet or when an injury is observed, clients are asked permission to take photo, these photos are for documentation only and not shared with others. LPA interviewed 5 clients and each denied the allegation, each client stated, they don’t mind being photographed, the photos taken are not inappropriate and don’t know if the photos are shared with anyone. (Continued on LIC9099-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260430120336

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: KAISER BEHAVIORAL CENTER WEST COVINA	FACILITY NUMBER: 198603289
	VISIT DATE: 05/08/2026

NARRATIVE

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Allegation: Staff are not meeting clients’ needs resulting in injuries
It is alleged that staff force clients to participate in activities during behavior episodes leading clients to sustain injuries. LPA interviewed 5 staff and each denied the allegation, staff stated that during a behavioral episode staff will remove the client from the room or have the room emptied to provide the client with a quiet and calm environment, they then try to de-escalate the behavior and calm the client down to prevent further aggression/behavior. LPA interviewed 5 clients and each denied the allegation, they stated they have never been injured during an activity and when a behavior happens they are removed from the group and a staff will help to calm them or the client with behavior down.
Allegation: Staff did not prevent a client from wandering from the facility
It is alleged that facility staff did not prevent a client from running into the parking lot unsupervised. LPA interviewed 5 staff and each denied the allegation, staff stated that when a client runs from staff they will go after the client and will communicate with other staff via walkie talkies for back up if needed so that clients are not left unattended. LPA interviewed 5 clients and each denied the allegation, C1-4 stated they have seen a client run away from their group but staff are always not too far behind and tell them to return and the client returns, C5 stated they have ran from their group before and staff redirected them right away and brought them back to their group. Each client stated they have not been left unsupervised.
Allegation: Staff force clients to participate in activities
It is alleged that clients are forced to participate even when they are sick or have severe behavior issues. LPA interviewed 5 staff and each denied the allegation, staff stated when a client is sick their home or parent is called, informed of the symptoms and the client is picked up or transported back to their home. LPA interviewed 5 clients and each denied the allegation, clients stated that if they are sick they are taken home and have not been forced to do activities when sick and when a behavior happens they are removed from the group and a staff will help to calm them or the client with behavior down.
Allegation: Staff did not prevent clients from having access to smoking items
It is alleged that vapes, cigarettes, and marijuana are accessible to clients. LPA interviewed 5 staff and each denied the allegation, staff stated that there are 2 clients at the facility that smoke and when they are given their smoke break they are accompanied by staff. Staff stated that the cigarettes are never accessible to other clients and they do not have vapes or marijuana at the facility. LPA interviewed 5 clients and each denied the allegation, clients stated that they have never seen any vapes, cigarettes, and marijuana at the facility.

Based on statements/interviews conducted with staff/clients, and review facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 held, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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