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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 11:23:02 AM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211019100743
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:
10:00 AM
MET WITH:Mayra Diaz, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has not returned resident's P & I monies.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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. During an interview with the administrator, it was reported that Client 1 (C1) was provided a check for P&I monies on 10/22/21. An interview with Inland Regional Center case worker revealed that the facility provided him with the check and he in turn provided the check to the responsible party of C1.

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 with and 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)
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