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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880910
Report Date: 04/23/2026
Date Signed: 04/23/2026 01:02:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2025 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250625143250
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: 2DATE:
04/23/2026
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Samuel Idowu, Lead staffTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Staff caused an injury to a client while in care

Staff hit a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA discussed the allegation with Administrator Holman and met with lead staff Samual Idowu and explained the elements of the complaint.

Allegation #1 - Interviewed Administrator (S1) relating to resident #1 (R1) in question, denies that staff at the facility caused an injury to R1. S1 also provided LPA with incidents of R1 exhibiting aggressive self injurious behaviors. LPA interviewed S2 and S3, who stated that they have not cause any injuries to R1. LPA interviewed R2, who states that he is not aware of staff causing injuries to R1. R2 states that staff treats him well at the facility. R1 no longer resides at the this facility and not available for interview.

Allegation #2 - Interviewed Administrator (S1) relating to resident #1 (R1) in question, denies that staff hit R1 while in care. S1 also provided LPA with documentation of R1's self injurous and aggressive behaviors. LPA Interviewed S2 and S3, who denies ever hitting R1 while in care or ever.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
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 56-AS-20250625143250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: K & J ADULT RESIDENTIAL
FACILITY NUMBER: 361880910
VISIT DATE: 04/23/2026
NARRATIVE
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LPA interviewed R2, who states that he is not aware of staff hitting R1 while in care. R2 states that staff treats him well at the facility. R1 no longer resides at the this facility and not available for interview.

Based on the information obtained there is not enough evidence that staff caused an injury to a client while in care and staff hit a client while in care. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and lead staff Idowu and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2