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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603297
Report Date: 06/03/2025
Date Signed: 06/03/2025 03:19:22 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
05/28/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250528163808
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: 8DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Ana GallegosTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Glenn Trueman, made a visit to Kendall Guest Home 2. The purpose of today's visit is to investigate the allegations above.
On today's visit LPA met with Administrator Ana Gallegos and explained the reason for the visit.
Medication was reviewed for Resident R1. Resident R2 no longer resides at the facility.
Interviews were conducted with Administrator Ana Gallegos and Staff S1 (telephonically.)
LPA received a report from the SG/Pomona Regional Center dated May 19, 2025. The report states that on February 12th, 2025 the Quality Assurance Specialist made an unannounced visit.
The following issue was identified:
On the evening of February 08, 2025, Staff S1 was not prepared with the water pitcher when starting to provide medication to the residents. Staff S1 left the room to get water, with Resident R1's medication in hand. Staff S1 was asked for water by Resident R2 and inadvertently gave Resident R2 medication in her hand that belonged to Resident R1. Medication included Atorvastatin 40MG Tablet, Amlodipine 5MG Tablet and Clonazepam 0.5MG Tablet. Staff S1 immediately contacted the administrator.




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: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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-20250528163808
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: 06/03/2025
NARRATIVE
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In regard to the allegation Staff mismanaged resident's medication, based on interviews conducted and information gathered Staff S1 confirmed that an error did occur on 02/08/2025.
Stated that Resident R2 was given R1's medication after she had left the room to get water.
Administrator stated that Resident 1's medication was given to Resident R2 and that it was a mistake.
Said that Staff S1 notified her immediately of the error.
San Gabriel Pomona Regional Center on an unannounced visit during a review of resident's medication observed there to be an error.

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.

In regards to the allegation Staff did not administer resident's medication as prescribed, based on interviews conducted and information gathered Staff S1 confirmed that Resident R2 did miss evening medication.
Administrator stated that per physician's advice Resident R2 was asked to skip medication Mapa 500MG Tablet, Atorvastatin 20MG Tablet for the evening and resume with medication as prescribed the following day 2/09/2025.
San Gabriel Pomona Regional Center's unannounced visit revealed the medication error and in the Corrective Action Plan dated May 19, 2025 a substantial Inadequacy and citation was issued for failure to administer medication as prescribed.

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: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250528163808
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: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2025
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
Medications usually prescribed for self-administration which have been authorized by the person's physician.
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Administrator is to provide in-service training to all staff on appropriate medication dispensing procedures and email the materials and list of attendees to LPA by the POC due date.
Proof of training submitted to LPA dated 02/11/2025.
Deficiency cleared.
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This requirement was not met as evidenced by:
Based on documentation and interview licensee failed to provide assistance with self administered medication with Resident R2 missing evening dose of medication and Resident R1's meds mismanaged which posed an Immediate Health and Safety 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: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3