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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547209265
Report Date: 07/19/2024
Date Signed: 07/19/2024 07:59:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/12/2024 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20240712100329
FACILITY NAME:KENYON HOME #2, THEFACILITY NUMBER:
547209265
ADMINISTRATOR:KENYON, DEBRAFACILITY TYPE:
735
ADDRESS:2541 E MARY AVETELEPHONE:
(999) 999-9999
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY:6CENSUS: 4DATE:
07/19/2024
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Licensee/Administrator (L/A) Debra KenyonTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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A Complaint visit was conducted by Licensing Program Analyst (LPA) K. Mcclurg. LPA met with Licensee/Administrator (L/A) Debra Kenyon.

Facility had notified LPA when it was determined that facility had bed bugs. Situation reviewed with Assistant Administrator/House Manager (AA) Steve Valverde during previous visit. Resident room had been cleaned out with all items removed & handled per Pest Control Service direction. According to L/A multiple attempts were made to contract service prior to 7/22/24, however, L/A did not receive call back, or available dates were further out. Currrent Pest Control Service was able to schedule at earliest
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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-20240712100329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: KENYON HOME #2, THE
FACILITY NUMBER: 547209265
VISIT DATE: 07/19/2024
NARRATIVE
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7/22/24. Facility continues to be slated for treatment 7/22/24. Pest Control Service provided a list of all things that must be done prior to treatment & how to handle items prior to returning to home after service. Facility has followed all pre-treatment to-do's & begun the treatment/storage of items to be brought back in after treatment.

The Department has investigated the allegation & determined it to be Substantiated.

Deficiency issued.

Exit interview conducted. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20240712100329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: KENYON HOME #2, THE
FACILITY NUMBER: 547209265
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds. The licensee shall take measures to keep the facility free of flies and other insects.
It was discovered by facility that a resident's room had bed bugs.
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Licensee has contracted with a licensed Pest Control Service for full house treatment 7/22/24. Treatment includes service follow-up & guidelines for pretreatment & post treatment.
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Pretreatments have been done & post treatment of items have been begun.
Copy of invoice of service performed 7/22/24 to be submitted to the Department by due date.
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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: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC9099 (FAS) - (06/04)
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