366408869-5-7-2025-56-AS-NBRN-DH3LJY-20250527084840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366408869
Report Date: 05/07/2025
Date Signed: 05/07/2025 10:18:13 AM

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
12/20/2023 and conducted by Evaluator Lavette Farlow

COMPLAINT CONTROL NUMBER: 56-AS-20231220102806

FACILITY NAME:	KONA HOME		FACILITY NUMBER:	366408869
ADMINISTRATOR:	PENDING		FACILITY TYPE:	735
ADDRESS:	1532 N. MULBERRY AVE.		TELEPHONE:	(909) 877-9159
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	4	CENSUS: 2	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Fausto Reyes, Administrator		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff did not prevent resident from eloping from the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation of and deliver findings to the above mentioned complaint. LPA met with Administrator, Fausto Reyes, who was informed of the reason for today's visit. The investigation consisted of interviews with clients, staff, and review of records.

It is alleged that staff did not prevent resident from eloping from the facility. Interview with resident one (R1) stated R1 used to leave the facility without permission when they would get upset. R1 also, stated that staff would attempted to stop R1 when R1 would try and leave. R1 stated they like it here and staff are nice to them. LPA interview with R4 revealed they sometimes R4 leaves without permission and staff tries to stop R4. LPA interviewed six (6) out of six (6) staff. LPA interview with S4, S5, and S6 stated they have not experienced any eloping behavior from residents in care. Interviews with S1, S2, and S3 reveal they have experienced eloping behavior and they try to stop and redirect residents behavior. Staff also, stated that if they can't redirect resident they call the police immediately.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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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Control Number 56-AS-20231220102806

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: 05/07/2025

NARRATIVE

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S1 stated that they do not chase residents because R1 has a history of not paying attention to the surrounding and running in front of cars. S1 stated the policy is to safely follow residents in care and redirect them.

Based on the information above, the allegation is 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 LIC 9099, and LIC 9099C was discussed, and a copy was provided to Administrator, Fausto Reyes.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

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