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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366410632
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:11:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/18/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240118170312
FACILITY NAME:KHEESA'S FAMILY HOMEFACILITY NUMBER:
366410632
ADMINISTRATOR:THOMAS, D'ANN TFACILITY TYPE:
735
ADDRESS:17269 SAN BERNARDINO AVE.TELEPHONE:
(909) 427-0957
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 3DATE:
05/03/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH: LaPorsha GrantTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff choked resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility House Manager LaPorsha Grant and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Facility staff choked resident.
LPA conducted interviews with clients regarding facility staff choking client, all clients denied being mistreated or being choked by staff. LPA asked clients if they have ever witnessed staff choke clients while in care, all clients denied witnessing staff choke clients while in care. LPA conducted interviews with staff and asked staff if they have witnessed staff choke clients while providing care, staff denied witnessing staff choking clients while in care. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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-20240118170312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KHEESA'S FAMILY HOME
FACILITY NUMBER: 366410632
VISIT DATE: 05/03/2024
NARRATIVE
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Unsubstantiated; meaning that 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) was discussed, and a copy was provided to Facility House Manager LaPorsha Grant.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2