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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408128
Report Date: 05/19/2021
Date Signed: 05/19/2021 10:25:56 AM



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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2019 and conducted by Evaluator Jennifer Semin
COMPLAINT CONTROL NUMBER: 18-AS-20191011091628
FACILITY NAME:KASSANDRA HOMEFACILITY NUMBER:
366408128
ADMINISTRATOR:MONDAY IDOWUFACILITY TYPE:
735
ADDRESS:4461 N. BRONSON STREETTELEPHONE:
(909) 887-9165
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:4CENSUS: 4DATE:
05/19/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Monday IdowuTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
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9
Client was kicked while in care
Staff withheld food from client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Monday Idowa
The investigation consisted of interviews with relevant parties.
The first allegation indicates the Client was kicked while in care. Staff interviews revealed that staff deny ever kicking any client in care. Client 1 (C1) stated they were kicked by staff but there were no witnesses to cooborate the allegation. Interviews with other clients revealed they have never been kicked or have seen any staff kick any client in care. Investigation did not reveal further information to either refute or corroborate the allegation.
The second allegation indicates staff withheld food from client while in care. Staff interviews revealed staff deny ever withholding food from clients in care. Interviews with other clients revealed staff have never withheld food from them.. LPA observations revealed the facility serves 3 meals per day and provides snacks and has snacks avaiable to cliebts to choose when desired. Investigation did not reveal further information to either refute or corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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-20191011091628
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
RIVERSIDE, CA 92507
FACILITY NAME: KASSANDRA HOME
FACILITY NUMBER: 366408128
VISIT DATE: 05/19/2021
NARRATIVE
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Based upon interviews and information gathered, and 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 at this time.

An exit interview was conducted with Mr. Idowa and a copy of this report was provided to the licensee.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2