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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202293
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:12:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
06/19/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230619164800
FACILITY NAME:KB CARE HOMEFACILITY NUMBER:
435202293
ADMINISTRATOR:KAITLYN BROWNELLFACILITY TYPE:
735
ADDRESS:1948 SEABEE PLACETELEPHONE:
(408) 823-6734
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY:6CENSUS: 5DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kaitlyn BrownellTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility illegally evicted resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegation. Administrator (ADM), Kaitlyn Brownell sat outside the facility and was unable to enter the facility due to a sickness. ADM provided consent to staff (S1) to sign the reports. LPA communicated with ADM via telephone.

On 06/19/2023, the Department received a complaint alleging the facility had illegally evicted a resident in care. On 06/27/2023, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s emergency information sheet, identification and emergency information, preplacement service plan, admission agreement, house rules, P&I form from April – June 2023, San Andreas Regional Center (SARC) quarterly report, safeguard of personal property and valuables, conservatorship paperwork, behavior consultant invoice, resident roster, and eviction letter. SEE LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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 7
Control Number 26-AS-20230619164800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: KB CARE HOME
FACILITY NUMBER: 435202293
VISIT DATE: 11/30/2023
NARRATIVE
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On 06/27/2023, 1 staff member was interviewed. Based on interview, the Administrator did not address the resident and the resident’s power of attorney (POA) on the eviction letter. The Administrator states to address the letter to R1’s service coordinator at San Andreas Regional Center (SARC) because the facility’s contract is with the representative's payee SARC, not with R1’s responsible party.

Based on record review, the eviction letter is addressed to R1’s SARC service coordinator. The reason for eviction is challenges of the parent both inside and outside of the home which created a heightened level of disruption with the other residents, which represents a violation of their client rights. The eviction letter does not include specific facts including date, place, witnesses, and circumstances based on Title 22 regulations.

The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency is being cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Kaitlyn Brownell over the telephone. ADM provided verbal consent to allow staff (S1) to sign the report. A copy of the report and appeal rights were provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 26-AS-20230619164800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: KB CARE HOME
FACILITY NUMBER: 435202293
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
80068.5(c)
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(c) The notice to quit shall state the reasons for the eviction, with specific facts supporting the reason for the eviction including the date, place, witnesses, if any, and circumstances. This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding of section 80068.5 by POC due date to LPA Dolores.
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Based on interview, record review, and observation the licensee did not ensure to include specific facts supporting the reason for eviction on the evicition letter including date, place, witnesses, if any which poses/posed an immediate health, safety, and personal rights risk to persons in care.
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ADM was informed the POC and/or extension request is due by 12/01/2023.
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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: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
06/19/2023 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20230619164800

FACILITY NAME:KB CARE HOMEFACILITY NUMBER:
435202293
ADMINISTRATOR:KAITLYN BROWNELLFACILITY TYPE:
735
ADDRESS:1948 SEABEE PLACETELEPHONE:
(408) 823-6734
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY:6CENSUS: 5DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kaitlyn BrownellTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff made an unauthorized purchase using resident's funds
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding for the above allegations. Administrator (ADM), Kaitlyn Brownell sat outside the facility and was unable to enter the facility due to a sickness. ADM provided consent to staff (S1) to sign the reports. LPA communicated with ADM via telephone.

On 06/19/2023, the Department received a complaint alleging that facility staff made an unauthorized purchase using R1’s funds. On 06/27/2023, the initial complaint investigation was conducted.

The following documents were obtained to include resident (R1)’s emergency information sheet, identification and emergency information, preplacement service plan, admission agreement, house rules, P&I form from April – June 2023, San Andreas Regional Center (SARC) quarterly report, safeguard of personal property and valuables, conservatorship paperwork, behavior consultant invoice and hours, and resident roster. SEE LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 26-AS-20230619164800
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: KB CARE HOME
FACILITY NUMBER: 435202293
VISIT DATE: 11/30/2023
NARRATIVE
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On 06/27/2023, 1 staff member was interviewed. Based on interview, R1’s responsible party verbally gave staff (S1) permission to purchase R1 a new mattress during a meeting involving the facility Administrator, R1’s responsible party, and two witnesses. S1 states the purchase of the mattress did not occur until a verbal agreement was stated with R1’s responsible party.

On 11/27/2023, 1 witness (W2) was interviewed. Based on interview, the conversation regarding the purchase of a new mattress for R1 was brought up at the end of a meeting between the facility Administrator, W2, day program staff, and R1’s responsible party. W2 states the conversation was really quick and W2 was unable to recall any objection or agreement regarding the facility Administrator purchasing a mattress for R1 using R1’s personal funds. It was stated the other witness during the meeting was also unable to recall the exact statements during the meeting.

Based on record review, the facility documented the purchase on R1’s P&I log. The mattress was returned by R1’s responsible party, which R1 was provided a partial refund.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Kaitlyn Brownell over the telephone. ADM provided verbal consent to allow staff (S1) to sign the report. A copy of the report was provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7