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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408869
Report Date: 10/25/2021
Date Signed: 10/25/2021 11:25:26 AM

Substantiated


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
09/13/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210913102616
FACILITY NAME:KONA HOMEFACILITY NUMBER:
366408869
ADMINISTRATOR:MAYRA DIAZFACILITY TYPE:
735
ADDRESS:1532 N. MULBERRY AVE.TELEPHONE:
(909) 877-9159
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 3DATE:
10/25/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mayra Diaz, AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Client AWOLd while in care
INVESTIGATION FINDINGS:
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On 10/25/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met with Administrator Mayra Diaz, explained the purpose of the visit and was granted entry.

The investigation, which consisted of interviews and record review, revealed the following. During an interview with the administrator, it was reported that Client 1 (C1) AWOL'd from the home on 9/10/21 through a bedroom window. C1 returned to the home unharmed via police escort on the same day. During an interview with C1, it was reported that they did AWOL from the home on 9/10/21.

Based on the LPA's observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 6) is being cited on the attached LIC9099D. An exit interview was conducted where this report, 9099D and LIC 811 were discussed with and provided to Mayra Diaz.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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 3
Control Number 18-AS-20210913102616
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: KONA HOME
FACILITY NUMBER: 366408869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
85065(b)
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Personnel Requirements - General The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement was not met as evidenced by:
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The facility will ensure that staffing is sufficent. The facility will continue to conduct checks on the clients to enure their safety.
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Based on interviews and record review, Client 1 (C1) AWOLD'd from the home on 9/10/21. C1 returned to the home on 9/10/21 unharmed, via police escort.

This is an immediate health and safety risk to clients 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
09/13/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210913102616

FACILITY NAME:KONA HOMEFACILITY NUMBER:
366408869
ADMINISTRATOR:MAYRA DIAZFACILITY TYPE:
735
ADDRESS:1532 N. MULBERRY AVE.TELEPHONE:
(909) 877-9159
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 3DATE:
10/25/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mayra Diaz, AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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9
Staff failed to treat client with dignity and respect
Untrained staff
Staff failed to meet client's needs
Staff are not allowing unvaccinated visitors
INVESTIGATION FINDINGS:
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On 10/25/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met with Administrator Mayra Diaz, explained the purpose of the visit and was granted entry.

The investigation, which consisted of interviews and record review, revealed the following. The LPA was unable to corroborate the allegation that staff failed to treat Client 1 (C1 ) with dignity and respect. Record review revealed that the facility staff have met the required training to meet the needs of the clients in care. The LPA was unable to corroborate the allegation that staff failed to meet C1's needs. An interview with the house manager revealed that the facility is not allowing unvaccinated visitors inside of the home, however visits can be conducted outdoors. The facility is in compliance with both CDC and CCL guidelines. 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 where this report and LIC 811 were discussed provided to Mayra Diaz.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3