<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408869
Report Date: 04/18/2025
Date Signed: 04/18/2025 03:56:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
03/24/2025 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20250324152937
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: 0DATE:
04/18/2025
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Fausto Reyes, AdministratorTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure hazardous items were safeguarded from clients
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Fausto Reyes, Administrator and explained the purpose of the visit. The investigation consists of interviews with residents, staff, record review, and a tour of the facility.

LPA Farlow conducted three (3) staff interviews. Three (3) out of the Three (3) staff stated they ensure hazardous items are safeguarded from clients. S2 stated on 03/21/2025, during a routine deep clean staff found a sleep aid, similar to Nyguil, Pepcid, scissors, and a box of thumb tacks. During LPA’s interview with S3, LPA observed the following items in the administrator drawer: medication for two (2) residents, plyer, and first aid scissor. LPA interviewed 4 residents and 4 out of 4 residents all stated usually staff keep hazardous items locked with a key. R1 stated sometimes scissors are left out. R1 stated they observed the scissors on the bookshelf. R1 also, stated staff was sleep and R1 got the medication from the locked closet when staff were asleep. After attempting to wake staff.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
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 56-AS-20250324152937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KONA HOME
FACILITY NUMBER: 366408869
VISIT DATE: 04/18/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met. An exit interview was conducted where this report LIC9099, LIC9099C, and LIC9099D, was discussed, and a copy was provided to Administration Fausto Reyes.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250324152937
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KONA HOME
FACILITY NUMBER: 366408869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2025
Section Cited
CCR
80087(g)(h)
1
2
3
4
5
6
7
80087(g)Disinfectant.. danger..clients shall be stored where inaccessible to clients.(h) Medicines.. stored as specified..separately... Section 80087(g) above.
1
2
3
4
5
6
7
Adminstrator agrees to review the regulation with all staff regarding securing of medication, and the important of securing hazardous items and making them inaccessible to clients in care. Adminsitrator will conduct a training and send to sign in sheet of all staff participating in the training to LPA by POC date.
8
9
10
11
12
13
14
Based on the evidence the licensee did not comply with the section cited above by staff not properly securing medication and by not making sure scissor and plyer are secured and locked away, which imposes an immediate health, safety and personal risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3