435202293-9-15-2021-26-AS-KHOS-C7AKG5-20210928075257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202293
Report Date: 09/15/2021
Date Signed: 09/15/2021 10:28:56 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2020 and conducted by Evaluator Steve Nguyen

COMPLAINT CONTROL NUMBER: 26-AS-20200728112253

FACILITY NAME:	KB CARE HOME		FACILITY NUMBER:	435202293
ADMINISTRATOR:	KAITLYN BROWNELL		FACILITY TYPE:	735
ADDRESS:	1948 SEABEE PLACE		TELEPHONE:	(408) 823-6734
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	6	CENSUS: 6	DATE:	09/15/2021
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Kaitlyn Brownell		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident being placed in dark room unattended
Resident educational activity needs not being met

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Nguyen arrived unannounced to deliver the complaint investigation finding. LPA met with Administrator, Kaitlyn Brownell, and explained the purpose of the visit.

On 07/28/2020 the Department received a complaint regarding the above allegations.

On 8/6/2020 LPA Marybeth Donovan opened the 10-day Complaint investigation via FaceTime Tele-Visit and advised the Administrator that the Department would be conducting the investigation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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 26-AS-20200728112253

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: KB CARE HOME	FACILITY NUMBER: 435202293
	VISIT DATE: 09/15/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Between 8/6/2020 and 9/8/2021 the Department reviewed records and interviewed Administrator, therapist, 1 staff, and 1 family member. Attempts were made, however; all clients at facility are nonverbal/ cognitively impaired. Records reviewed includes but are not limited to: resident and staff rosters, three resident records to include emergency contact information, physician's report, appraisal needs and services plan and or available IPP.

Therapist does not have any further details to add. Family member denies the allegations. Administrator and staff, both denies the allegations. A review of the records indicated that C1’s continued to have programming via Zoom and that there was no disruption in the program.

Based on information from interviews conducted and records reviewed, although the allegation listed above 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 allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Administrator, Kaitlyn Brownell and a copy of this report provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2