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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880910
Report Date: 02/07/2025
Date Signed: 02/07/2025 10:50:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2021 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210723092701
FACILITY NAME:K & J ADULT RESIDENTIALFACILITY NUMBER:
361880910
ADMINISTRATOR:HOLMAN, JERRHONDAFACILITY TYPE:
735
ADDRESS:5091 ROOSEVELT STTELEPHONE:
(562) 225-1038
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:4CENSUS: 3DATE:
02/07/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Samuel Idowu- CaregiverTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member inappropriately handled resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Samuel Idowu and explained the purpose of the visit. The investigation consisted of observations, and interviews.

First allegation: Staff member inappropriately handled resident in care. Regarding the allegation “Staff member inappropriately handled resident in care” LPA conducted interviews with Client #2 and Client #3 who informed LPA that they have not experienced staff mistreat them or handle them in a rough manner. C#2 and C#3 informed LPA that they feel safe and like the facility. LPA conducted interview with Client #1 who informed LPA that the incident occurred a while ago and does not really remember however, C#1 informed LPA that staff did not mistreat client or handled client inappropriately the day of the incident. Client #1 informed LPA that C#1 wanted to live with former girlfriend and no longer live at the facility. LPA conducted interviews with Staff #1 and Staff #2 regarding the allegation “Staff member inappropriately handled client in care” Staff #1 and Staff #2 denied handling clients inappropriately, and denied witnessing staff mistreat clients in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
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 2
Control Number 18-AS-20210723092701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: K & J ADULT RESIDENTIAL
FACILITY NUMBER: 361880910
VISIT DATE: 02/07/2025
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 corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated: meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Samuel Idowu at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2