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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408869
Report Date: 05/07/2025
Date Signed: 05/07/2025 10:19:27 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
12/18/2023 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20231218095440
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: 2DATE:
05/07/2025
UNANNOUNCEDTIME BEGAN:
07:10 AM
MET WITH:Fausto Reyes, AdministratorTIME COMPLETED:
08:40 AM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Staff did not use appropriate restraint on client causing injury.
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 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 use appropriate restraint on client causing injury. Interview with client 1 (C1) stated that they used to lie a lot and make up stories. C1 stated they like it here and staff never hurt them. LPA interview with C2, C3, and C4 revealed they have not seen any staff causing injury to clients in care and they have not had any injuries from staff. LPA interviewed six (6) staff, and six out of six staff reveal not causing injury to clients in care. Two out of two staff stated they have used CPI on a few client over the years but never caused any injuries. Two out of two staff stated C1 would self harm and bang C1 head on the floor or scratch self.

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)
Page: 1 of 2
Control Number 56-AS-20231218095440
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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32
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)
Page: 2 of 2