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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700578
Report Date: 03/28/2025
Date Signed: 04/01/2025 06:40:31 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2025 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250213222950
FACILITY NAME:KAVERE SERVICES-LIFE SKILLS PROGRAMFACILITY NUMBER:
392700578
ADMINISTRATOR:GULLEY, AMANDAFACILITY TYPE:
735
ADDRESS:3716 JAGGER LNTELEPHONE:
(209) 475-8868
CITY:STOCKTONSTATE: ZIP CODE:
95212
CAPACITY:5CENSUS: 3DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Isaac Herrera TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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a staff member was Requesting funds from a resident.
INVESTIGATION FINDINGS:
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On 03-28-25, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Administrator Isaac Herrera and explained the purpose of the visit.

LPA interviewed R1-R3 and S1. Based on interviews and the facility's own investigation during which S1 admitted to taking money, there is a preponderance of evidence to prove the alleged violations occurred, as a result the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

The facility terminated the employee and reported all allegations as soon as the were learned of.

An exit interview was conducted and a copy of this report and appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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 27-AS-20250213222950
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KAVERE SERVICES-LIFE SKILLS PROGRAM
FACILITY NUMBER: 392700578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2025
Section Cited
CCR
80072(a)(1)
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Each client shall have personal rights which include, but are not limited to, the following:..To be accorded dignity in his/her personal relationships …To be accorded safe, healthful and comfortable accommodations…This requirement was not met as evidenced by:
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Staff was terminated on 02/18/25 and is no longer at the facility. Remaining staff completed mandated training with a focus on money areas. Administrator will email proof of training to LPA by COB 04/04/2025.
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Based on interviews, staff admitted to having asked a resident and other staff for money. which poses a potintial Health, Safety or Personal Rights risk to persons 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: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2