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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423857
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:31:17 AM

Substantiated


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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211115094656
FACILITY NAME:MCKINLEY CARE HOMEFACILITY NUMBER:
366423857
ADMINISTRATOR:APRILLELYN PANALIGANFACILITY TYPE:
735
ADDRESS:9895 MCKINLEY ST.TELEPHONE:
(909) 910-4633
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:4CENSUS: 4DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:April Panaligan, administrator/caregiverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Client sustained injuries while in care
INVESTIGATION FINDINGS:
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On 11/17/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of investigating the above allegations. LPA met with April Panaligan explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and file review revealed the following:
Allegations 1: Client sustained injuries while in care
During an interview with the administrator, it was reported that Client 1 (C1) sustained falls on 11/8/21, 11/10/21, 11/11/21 and 11/12/21. All 4 staff interviews revealed C1 refuses to use their wheel chair and is combative when staff attempt to assist C1 in ambulating. The LPA observed an incident log that detailed each of the falls. On 11/8/21 C1 fell and hit their head, which caused bruising to the right side of his head.
***Continued on 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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 5
Control Number 18-AS-20211115094656
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
RIVERSIDE, CA 92507
FACILITY NAME: MCKINLEY CARE HOME
FACILITY NUMBER: 366423857
VISIT DATE: 11/17/2021
NARRATIVE
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 ***continued from 9099***

On 11/10/21 C1's fall resulted in bruising to the left side of his head and the left side of their body. C1 sustained two falls on 11/11/21 which resulted in bruising to right shoulder and the left side of their head. On 11/12/21 C1 fell and hit their head which resulted in a red mark on their left side of their head. C1 was sent to the hospital because they were very agitated and staff did not want C1 to further injure themselves with additional falls.
The LPA interviewed C1, however, when asked about the bruising and the falls, C1 responded that they did not know. A review of C1's Individual Placement Plan (IPP) indicates C1 has no safety awareness and requires supervision at all times to prevent injury/harm. An interview with Client 2 (C2) did not yield any pertinent information due to C2 being non-verbal. The LPA was not able to interview Client 3 (C3) due to being admitted to the hospital or Client 4 (C4) due to them being at their day program. The LPA was able to observe that C1 had bruises that appeared to be in the end stages of healing to the left and right sides of their head.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, 9099C, 9099D, LIC 811 and appeal rights were provided to April Panaligan.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211115094656

FACILITY NAME:MCKINLEY CARE HOMEFACILITY NUMBER:
366423857
ADMINISTRATOR:APRILLELYN PANALIGANFACILITY TYPE:
735
ADDRESS:9895 MCKINLEY ST.TELEPHONE:
(909) 910-4633
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:4CENSUS: 4DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:April Panaligan, administrator/caregiverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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2
3
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9
Client is not being properly fed while in care
INVESTIGATION FINDINGS:
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On 11/17/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of investigating the above allegations. LPA met with April Panaligan explained the nature of the visit and was granted entry.

Allegation 2: Client is not being properly fed while in care
The LPA was not able to obtain any pertinent information from Client 1 because when asked about being properly fed, C1 responded that they did not know. Staff 1 (S1), Staff 2( S2), Staff 3 (S3) and Staff 4 (S4) all denied that C1 is not properly fed. It was reported that C1 has been ill and experienced a decline in their appetite, which may have contributed to their minor weight loss. C1 was admitted to the facility on August 25,2021. On August 26,2021, C1 weighed 145 lbs. On September 27,2021 C1 weighed 151 lbs.
***Continued on 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211115094656
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
RIVERSIDE, CA 92507
FACILITY NAME: MCKINLEY CARE HOME
FACILITY NUMBER: 366423857
VISIT DATE: 11/17/2021
NARRATIVE
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 ***Continued from 9099***

On October 25, 2021 C1 weighed 140 lbs. An interview with Client 2 (C2) did not yield any pertinent information due to C2 being non-verbal. The LPA was not able to interview Client 3 (C3) due to being admitted to the hospital or Client 4 (C4) due to them being at their day program. The food menu for November indicates the clients in care are being provided nutritious meals and snacks. The menu also indicates that the menu can be changed based on the clients' choice.

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, therefore the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted where this report, 9099C and LIC 811 were provided to April Panaligan.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20211115094656
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
RIVERSIDE, CA 92507

FACILITY NAME: MCKINLEY CARE HOME
FACILITY NUMBER: 366423857
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
CCR
80065(a)
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Personnel Requirements: Facility personnel shall be...competent...and employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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The administrator will review the cited regulation in it's entirety with staff, then provide a signed copy to the department by the POC date.
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Based on interviews, observation and file review, Client 1 (C1) sustained falls on 11/8/21, 11/10/21, 11/11/21 and 11/12/21, which resulted in bruising. This is a potential health and safety risk to clients 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: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5