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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426704
Report Date: 12/08/2021
Date Signed: 12/08/2021 01:59:06 PM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/07/2021 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211207102628
FACILITY NAME:KENNETH ADULT RESIDENTIAL VFACILITY NUMBER:
366426704
ADMINISTRATOR:CHAVEZ, SYLVIAFACILITY TYPE:
735
ADDRESS:6251 BRECKINRIDGE LN.TELEPHONE:
(909) 464-9460
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 6DATE:
12/08/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Karina FernandezTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Staff overmedicated resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Rohit Lama and Javier Prieto conducted an unannounced visit to the facility in order to investigate the allegation that: Staff overmedicated resident. LPAs met with Facility’s Assistant Administrator, Karina Fernandez (S1). LPA obtained Resident #1 (R1)’s folder and MAR Log. By reviewing R1’s folder, LPAs were able to identify the medications and respective dosages that R1’s physician has prescribed to R1.Review of MAR Log shows that staff are providing the correct dosages of medications to R1 and at the appropriate times. LPAs interviewed R1. R1 stated the following: Likes being at the facility, has no problem with the medications that is being given. LPAs also interviewed S1 and Staff #2 (S2). Both S1 and S2 stated that the medications and dosages are currently being fine-tuned by R1’s physician to better suit R1. Both S1 and S2 also stated that R1’s behavior is at baseline with the medications and that they have not had any issues with the current dosages.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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 2
Control Number 18-AS-20211207102628
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: KENNETH ADULT RESIDENTIAL V
FACILITY NUMBER: 366426704
VISIT DATE: 12/08/2021
NARRATIVE
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Based on the information obtained there is not enough evidence that: Staff overmedicated resident. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2