<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 03:57:52 PM

Unsubstantiated


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
03/26/2025 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20250326145646
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: 3DATE:
04/18/2025
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Fausto Reyes, AdministratorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speaks inappropriately to client in care.
Staff does not ensure client is treated with dignity and respect by other clients in the facility.
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.

It is alleged that staff speaks inappropriately to clients in care. LPA Farlow conducted interviews with three (3) out of three (3) staff. S1, S2, and S3 stated they have not seen neither have they spoken to clients in care inappropriately. LPA Farlow also interviewed four (4) out of four (4) clients in care. C1, C2 and C4 stated they heard or experience staff yelling at them or another client in care. C1, C2, and C4 stated staff yelled when breaking up a fight between C1 and C2. During the course of the interviews, and investigation it was discovered that staff have spoken in a louder tone only to deescalate verbal fights or altercation among residents in care.

It is alleged that staff does not ensure client is treated with dignity and respect by other clients in the facility. Three (3) out of the Three (3) staff stated they ensure clients are treated with dignity and respect by other clients in the facility. The staff also, stated when there is conflict with clients in care they will attempt to separate the client by redirecting client to another area in the home, or in their room. LPA interviewed 4 out of 4 clients and it was revealed that C1 and C2 are having difficulties getting a long and often times have to be separated.
Unsubstantiated
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 2
Control Number 56-AS-20250326145646
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 information above, the allegations are unsubstantiated. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed, and a copy was provided to Administrator, 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 2