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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425631
Report Date: 12/16/2025
Date Signed: 12/16/2025 10:57:45 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
10/12/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231012130054
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ALTOFACILITY NUMBER:
366425631
ADMINISTRATOR:MICHAEL VAN NORMANFACILITY TYPE:
735
ADDRESS:25702 ALTO CTTELEPHONE:
(909) 883-2099
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:4CENSUS: 4DATE:
12/16/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michael Van Norman, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are financially abusing residents
Staff did not meet residents’ medical needs
Facility is operating out of ratio
Staff are falsifying documents
Staff did not provide adequate food service
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conclude a complaint investigation regarding the above allegations. LPA Prieto met with Administrator Van Norman and explained the elements of the complaint.

Allegation #1 - LPA Prieto reviewed financial records for resident #1 (R1), R2, R3 and R4 and found them correct and up to date.

Allegation #2 - LPA interviewed facility nursing staff #1 (S1), who states all residents are checked daily for body temperature, body checks, and bowel movements. LPA also reviewed Medical Administration Records (MAR) for R1, R2. R3 and R4 and found them to be accurate and up to date.

Allegation #3 - Facility is sufficiently staff to meet the needs of the clients in care. R1 has a 3 on 1, which is met with the facility being staffed with 4 to 5 staff each day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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-20231012130054
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: KAISER SPECIALIZED RESIDENTIAL ALTO
FACILITY NUMBER: 366425631
VISIT DATE: 12/16/2025
NARRATIVE
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5
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9
10
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Allegation #4 - LPA reviewed medical and financial records for R1, R2, R3 and R4 and found no errors or discrepancies in these files.

Allegation #5 - LPA reviewed facility food supply during today's investigation and found to be sufficient with perishables and non perishables to meet the needs of the clients in care.

Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Administrator Van Norman and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2