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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425631
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:33:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2020 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200924094919
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ALTOFACILITY NUMBER:
366425631
ADMINISTRATOR:HARBIN, ADRIANNAFACILITY TYPE:
735
ADDRESS:25702 ALTO CTTELEPHONE:
(909) 883-2199
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92407
CAPACITY:4CENSUS: DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff, Robin SwiftTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not report incident within mandated timeframe
INVESTIGATION FINDINGS:
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On 9/27/2023, Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations and deliver findings. LPA met with Staff, Robin Swift, who was informed of the purpose of the visit. During the investigation, the department conducted interviews and conducted records reviews.

Regarding, “Staff did not report incident within mandated timeframe” it was alleged that incident occurring on 8/27/2020 was reported after the seven (7) reporting time period for Reporting requirements. It was documented in staff declaration that incident occurring on 8/27/2020 was reported by staff to the facility on 9/21/2020. The facility reported the incident on 9/23/2020 to the regional office. Therefore the allegation that the facility failed to report the incident within the required time frame is found to be substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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 4
Control Number 18-AS-20200924094919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL ALTO
FACILITY NUMBER: 366425631
VISIT DATE: 09/29/2023
NARRATIVE
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Findings that are substantiated mean that the preponderance of the evidence standard has been met.

An exit interview was conducted where this report, appeal rights, and 9099-D page were reviewed and provided to Staff, Robin Swift.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20200924094919
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL ALTO
FACILITY NUMBER: 366425631
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
80061(b)(1)(E)
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(b) Upon the occurrence…of any of the events specified…a written report…shall be submitted to the licensing agency within seven days…(1)…(E)Any unusual incident…which threatens the physical…safety of any client.
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The licensee agreed conduct an inservice with staff on reporting requirments by the POC due date.
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This requirement was not met as evidenced by: Based on records review incident with R1 and possible physical abuse was reported past the seven days. This poses a potential health safety or personal rights risk to residents 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: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4