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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547202394
Report Date: 08/13/2025
Date Signed: 08/14/2025 09:37:21 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2025 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20250812114441
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL CONSTITUTIONFACILITY NUMBER:
547202394
ADMINISTRATOR:RANKIN-VILLALOBOS, LEXISFACILITY TYPE:
735
ADDRESS:1268 CONSTITUTION STTELEPHONE:
(559) 685-9006
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:5CENSUS: 3DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator, Lexis Rankin-Villalobis
District Manager, Jose Marquez		TIME COMPLETED:
06:31 PM
ALLEGATION(S):
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Staff handled resident in a rough manner resulting in injury
INVESTIGATION FINDINGS:
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On 08/13/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct the required 10 day site inspection. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility. District Manager, Jose Marquez, was present during the visit.

The Department has investigated the allegation, based on records review and interviews conducted, Resident R1 had a behavioral episode where they bit Staff S1's finger. Staff S1 reacted to R1's behavior by pushing R1 in their face, resulting in a fractured nose. The incident was said to have occurred on the NOC shift between 2:30AM and 4:00AM. LPA observed the communication logs entered by S1 on the date of incident stating R1 slept through the night without any incidents. This is a false claim.

Based on interviews conducted and records review, Staff S3 came on shift at 6AM and observed R1's nose to be bleeding and the bleeding would not stop. S3 reported to Administrator at the time of observation. Staff S1 and Staff S2 did not seeking medical attention for R1 and did not report the incident to Administrator. Staff S2 was not actively involved in supporting R1 during the behavioral incident. At 8:00AM, Administrator and S3 transported R1 for medical treatment where R1 received medical treatment. R1 was diagnosed with a contusion/fractured nose and was released home same day.

(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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 3
Control Number 24-AS-20250812114441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL CONSTITUTION
FACILITY NUMBER: 547202394
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2025
Section Cited
CCR
80065(a)
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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs ...
This requirement was not met as evidenced by records review and interviews conducted: Staff S1 and Staff S2 did not seeking medical attention for R1 and did not report the incident to Administrator. S1 reported to S3 on shift change that R1 had a behavior, but did not state their was an injury.
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Administrator provided proof of all staff training for dated 06/25/25, 6/30/25, 07/17/25, and 07/30/25 : Trauma informed support, personal rights, team communication , abuse preventing, recognizing and reporting, emergency interventions, empathy and compassion in service delivery, effective documentation, rights of individuals with IDD. An immediate civil penalty in the amount of $500 is hereby assessed. **POC cleared**
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 Staff S1 did not implement their emergency intervention training and reacted to R1's behavior by pushing R1 in the face resulting in a fractured nose.
If not corrected, this poses and immediate risk to the health safety and personal rights of residents in care. A civil penalty in the amount of $500 is hereby assessed.
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Type A
08/14/2025
Section Cited
CCR
80012(a)
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80012
(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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Staff S1 was terminated from employment. Administrator provided proof of all staff training for dated 06/25/25, 6/30/25, 07/17/25, and 07/30/25 : LPA obtained training records for all staff: Trauma informed support, personal rights, team communication , abuse preventing, recognizing and reporting, emergency interventions, empathy and compassion in service delivery, effective documentation, rights of individuals with IDD. **POC Cleared**
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Based on records review, incident report received states it occurred on the NOC shift between 2:30AM and 4:00AM. Records show, S1 documented on the shift log that "R1 slept through the without any incidents" This is a false claim. If not corrected, this poses and immediate risk to the health safety and personal rights of residents 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: Brenda Chan
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20250812114441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL CONSTITUTION
FACILITY NUMBER: 547202394
VISIT DATE: 08/13/2025
NARRATIVE
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(Continued from LIC 9099)

Based on interviews and records review, and per California Code of Regulations (CCR), Title 22, Division 6, Chapter 6, deficiencies are being cited on the attached 9099D. If not corrected, this poses and immediate risk to the Health Safety and/or personal rights of residents in care. An immediate civil penalty in the amount of $500 is being assessed for care and supervision. Issuance of additional civil penalties, if any, are pending and currently under review.

LPA conducted an exit interview with Administrator and District Manager. Plans of corrections were observed to be completed. LPA provided copies of the reports and appeal rights at the time of visit.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3