486804045-4-29-2025-21-AS-KMOA-DGFTYM-20250507150857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804045
Report Date: 04/29/2025
Date Signed: 04/29/2025 04:01:02 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20250131160043

FACILITY NAME:	KEARNEY COMMUNITY SUPPORT HOME		FACILITY NUMBER:	486804045
ADMINISTRATOR:	COLEMAN, CLARENCE JR.		FACILITY TYPE:	735
ADDRESS:	100 KEARNEY WAY		TELEPHONE:	(707) 548-3646
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	4	CENSUS: 4	DATE:	04/29/2025
		UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:	Clarence Coleman, Jr., Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff do not treat residents with dignity and respect
Facility staff are not properly dispensing medication as prescribed
Facility staff are not preventing altercations between clients in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 04/29/2025 to continue the investigation and deliver findings regarding the above allegations.

The complaint alleges Facility staff do not treat residents with dignity and respect. It is alleged that Staff (S1) refers to Client (C1) with derogatory names. LPA Nakagawa conducted interviews with three (3) of four (4) clients (C1, C2, C3) as well as three (3) staff (S1, S2, S3). Client (C4) was off site at the time of LPA's visits. Three (3) of three (3) clients and three (3) of three (3) staff responded in the affirmative that it was a happy home and that the Administrator and other staff treated them like family.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250131160043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KEARNEY COMMUNITY SUPPORT HOME	FACILITY NUMBER: 486804045
	VISIT DATE: 04/29/2025

NARRATIVE

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Continued from 9099....

Based on the evidence, including interviews, the allegation that Facility staff do not treat residents with dignity and respect is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

The complainant alleges that Facility staff are not properly dispensing medications. LPA reviewed records and conducted interviews. There were no irregularities documented in the care notes or the MAR from the dates 12/01/2024 through 01/31/25. LPA asked two (2) of four (4) clients (C1, C2) if staff had ever given them medications incorrectly and they replied "no". Through interviews, C1, C2 stated that "they received their medications on time and did not have a problem with staff". LPA also interviewed staff (S1, S2) if there were any medications errors during the dates indicated. S1 and S2 stated that there were no errors made. Therefore, based on the evidence found, the allegation that Facility staff are not properly dispensing medications is unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did nor did not occur, therefore the allegation is unsubstantiated.

The complainant alleges that Facility staff are not preventing altercations between clients in care. LPA Nakagawa reviewed incident reports, interviewed staff (S1 , S2) and clients (C1, C2) and found that there have been no incidents between clients at the facility. Therefore, based on the evidence obtained and interviews conducted the allegation that staff are not preventing altercations between clients in care is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

LIC9099 (FAS) - (06/04)

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