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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603297
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:25:51 PM

Substantiated


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
07/31/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240731141906
FACILITY NAME:KENDALL GUEST HOME 2FACILITY NUMBER:
198603297
ADMINISTRATOR:GALLEGOS, ANAFACILITY TYPE:
740
ADDRESS:4700 N MAXSON RDTELEPHONE:
(909) 631-8521
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY:9CENSUS: 9DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ana GallegosTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility failed to meet reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Ana Gallegos and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation.
At today's visit the following was done:
Resident and Staff Roster submitted.
Interview was conducted with the Administrator.
LPA reviewed Resident R1 and Resident R2's file and the following was submitted:
Resident ID Notes, Physician's Report, and Face Sheet.
Special Incident Report (SIR) dated 01/02/24 was submitted.
In regards to the allegation Facility failed to meet reporting requirements, based on interview conducted and information gathered it was confirmed by the Administrator that the Special Incident Report (SIR) was not submitted within the 7 day time frame. Administrator stated that staff documented the incident in client notes, but did not inform the Administrator or any other agencies.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 08/08/2024
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 3
Control Number 28-AS-20240731141906
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: KENDALL GUEST HOME 2
FACILITY NUMBER: 198603297
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2024
Section Cited
CCR
87211(a)1(D)
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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.


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Facility to submnit by POC due date, training regarding the reporting of special incidents and submit the signed log of those who attended.
Facility submitted proof of training that was given by the Regional Center on 01/25/24.
Deficiency cleared.
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This requirement is not met as evidenced by:
Facility failed to report a Special Incident Report involving Resident R1 inappropriately touching Resident 2 which is caused a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240731141906
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: KENDALL GUEST HOME 2
FACILITY NUMBER: 198603297
VISIT DATE: 08/08/2024
NARRATIVE
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Administrator upon reading through Resident ID notes at a later date immediately issued the SIR and contacted Regional Center and APS.
The incident involved Resident R1 inappropriately touching Resident R2.
It should be noted that Resident R1 was relocated to another facility.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per Title 22, deficiencies are cited.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3