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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366412346
Report Date: 07/11/2023
Date Signed: 07/11/2023 11:39:58 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230623122908
FACILITY NAME:KENNETH ADULT RESIDENTIAL IIIFACILITY NUMBER:
366412346
ADMINISTRATOR:CHAVEZ, JAMESFACILITY TYPE:
735
ADDRESS:12379 LORAINE AVE.TELEPHONE:
(909) 364-0137
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 4DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sylvia Chavez, LicenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not report a resident's death to Community Care Licensing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conclude a complaint investigation regarding the above allegations. LPA Javier met with Licensee Sylvia Chavez and discussed the purpose of the visit. The investigation consisted of interviews with staff and collected documentation.

Regarding allegation that facility did not report a resident's death to Community Care Licensing, licensee provided documentation of an incident regarding resident #1 (R1) that was phoned and sent to the Licensing office detailing the events on that date.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
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-20230623122908
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: KENNETH ADULT RESIDENTIAL III
FACILITY NUMBER: 366412346
VISIT DATE: 07/11/2023
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 obtained there is not enough evidence that facility did not report a resident's death to Community Care Licensing. Therefore, the allegations is deemed UNSUBSTANTIATED at this time.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Licensee Chavez at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2