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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413139
Report Date: 01/29/2024
Date Signed: 02/02/2024 02:40:27 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
12/27/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20231227151406
FACILITY NAME:KALIA HOMEFACILITY NUMBER:
366413139
ADMINISTRATOR:PENDINGFACILITY TYPE:
735
ADDRESS:902 N. LINDEN AVETELEPHONE:
(909) 429-4418
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:4CENSUS: 3DATE:
01/29/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Brianna Edge, Direct Support StaffTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff did not ensure that resident was administered their medication(s) as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Kalia Home unannounced to deliver the findings of the complaint investigation. LPA greeted and granted entry by Direct Support Staff, Brianna Edge LPA introduced self and stated the purpose of the visit. LPA was informed, Administrator was out of the facility at the time of the visit.

During the complaint investigation, LPA collected documentation and interviewed staff. It is alleged that Staff did not ensure that resident was administered their medication(s) as prescribed. According to the Medication Administrative Records, (MARS) R1 did not miss or refuse any prescribed medications while residing at the facility. During staff interviews, it was revealed that R1 was admitted to the hospital on several occasions; at which time her medications were provided during admission. Healthcare staff recommended R1 see a specialist for a specific medication; R1 missed appointments made with the specialist; due to being admitted to the hospital at each time of the scheduled appointments.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
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-20231227151406
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: KALIA HOME
FACILITY NUMBER: 366413139
VISIT DATE: 01/29/2024
NARRATIVE
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Staff scheduled and rescheduled three different appointments with the specialist to get a prescription for the medication. Staff confirmed R1 is no longer a resident of the facility.

Based on 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 with Facility Representative. This report was reviewed, discussed and provided.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2