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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366410632
Report Date: 08/23/2024
Date Signed: 08/23/2024 02:35:05 PM

Substantiated


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
08/10/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230810122718
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:
08/23/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:India Butler-Support StaffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff handled client in a rough manner causing injury
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 Caregiver India Butler and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff handled client in a rough manner causing injury. Regarding the allegation “Staff handled client in a rough manner causing injury” LPA conducted a report review completed by the Investigation Branch. During the review of records LPA discovered that audio/video was obtained and reviewed by the Investigation Branch. Report indicated that through audio recording staff is heard using profanity language towards client in addition, in the video staff can be seen and heard physically assaulting client. Based on the evidence gathered during the investigation, the above allegation is Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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 4
Control Number 56-AS-20230810122718
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: 08/23/2024
NARRATIVE
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Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights 80072 (3) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along
with a copy of the appeal rights. to Facility Caregiver India Butler.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230810122718
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
HSC
80072(3)
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Personal Rights 80072 (3)... To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature, including but not limited to: interference with the daily living function, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.
This requirement is not met as evidence by:
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Licensee has agreed to review Personal Rights Regulation Provide training to all staff support.Licensee will ensure that training is signed and dated by all support staff and email proof to LPA Guerrero by POC date 9/27/2024.
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Based on record review, the licensee did not ensure Personal Rights to be met for client, which poses an immediate Health, Safety, or Personal Rights risk for people in care.
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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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
08/10/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230810122718

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: 6DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:India Butler-Support StaffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff sexually assaulted a client
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 Caregiver India Butler and explained the purpose of the visit. The investigation was conducted by Department staff and consisted of interviews and review of records.

Department staff interviewed Resident R1 who denied being sexually assaulted by Staff 1 (S1). However, R1 indicated that S1 attempted to touch R1’s private area. The local police department also interviewed R1 who reported that R1 was sexually assaulted by S1. Police department interviewed S1 who denied sexually assaulting R1. Due to the inconsistent statement of R1 being sexually assaulted, LPA found insufficient evidence to substantiate the sexual assault allegation Therefore, the alleged allegation of sexual assault has been determined Unsubstantiated. 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 Caregiver India Butler
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4