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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015650058
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:21:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2023 and conducted by Evaluator George Karkazis
PUBLIC
COMPLAINT CONTROL NUMBER: 14-CR-20231113153055
FACILITY NAME:R.E.F.U.G.E.III, THEFACILITY NUMBER:
015650058
ADMINISTRATOR:KHEA GUMBSFACILITY TYPE:
733
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 1DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Khea Gumbs, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to report incidents to the department in a timely manner

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/21/2024 at 2:58 PM, Licensing Program Analysts (LPA’s) George Karkazis and Jasmine Cardeno conducted an unannounced inspection at REFUGE III, and met with Khea Gumbs, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged the facility failed to report incidents to the department in a timely manner. LPA Karkazis conducted confidential interviews, facility representatives stated that incident reports were sent late due to an unforeseen emergency. LPA Karkazis conducted document research. On November 8, 2023, the facility sent three incident reports to the San Bruno Incident Report Inbox. All three were marked "late" by the officer on duty. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

At this time there is no citation issued. A Technical Violation Reporting Requirements 80061(b) was issued during 11-13-23 Case Management. An exit interview was conducted, Appeal Rights discussed, and a copy of this report were given to Khea Gumbs, Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Isabel Diego
LICENSING EVALUATOR NAME: George Karkazis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2023 and conducted by Evaluator George Karkazis
PUBLIC
COMPLAINT CONTROL NUMBER: 14-CR-20231113153055

FACILITY NAME:R.E.F.U.G.E.III, THEFACILITY NUMBER:
015650058
ADMINISTRATOR:KHEA GUMBSFACILITY TYPE:
733
ADDRESS:3906 LOMA VISTA AVENUETELEPHONE:
(510) 530-8541
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:6CENSUS: 1DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Khea Gumbs, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client was assaulted by staff

Lack of Supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/21/2024 at 2:58 PM, Licensing Program Analysts (LPA’s) George Karkazis and Jasmine Cardeno conducted an unannounced inspection at REFUGE III, and met with Khea Gumbs, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged client was assaulted by staff and lack of supervision. LPA Karkazis and conducted confidential interviews, and conducted document research, in which inconsistent information was provided.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED. A copy of this report was given to Khea Gumbs, Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Isabel Diego
LICENSING EVALUATOR NAME: George Karkazis
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2