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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408869
Report Date: 12/19/2024
Date Signed: 12/19/2024 01:39:52 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
10/11/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20221011131421
FACILITY NAME:KONA HOMEFACILITY NUMBER:
366408869
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:1532 N. MULBERRY AVE.TELEPHONE:
(909) 877-9159
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 4DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
12:15 AM
MET WITH:Administrator, Fausto ReyesTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not use appropriate restraint on client causing injury
Staff did not have adequate food
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to deliver the findings on the complaint investigation regarding the allegations mentioned above. LPA met with Administrator Fausto Reyes, who allowed entry into the facility and was informed of the purpose of the visit.

LPA Allen conducted interviews with residents and staff members and toured both the inside and outside of the facility.

The staff members interviewed stated that residents in care have never been treated inappropriately at any time. The residents confirmed that the staff members treat them with respect and have never mistreated them in any way. LPA attempted to interview Resident 1 (R1), but they no longer live at the facility and their current location is unknown.During the tour, LPA observed that the facility has a variety of perishable and non-perishable food items appropriate for the number of residents in care. Additionally, there were no health and safety concerns noted during the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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-20221011131421
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: KONA HOME
FACILITY NUMBER: 366408869
VISIT DATE: 12/19/2024
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegations is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted where this report was discussed and provided to Administrator, Fausto Reyes at the conclusion of the visit with appeals rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2