015650058-10-11-2021-14-CR-ZHAM-C82N69-20211022101046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015650058
Report Date: 10/11/2021
Date Signed: 10/11/2021 05:19:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/06/2021 and conducted by Evaluator Christopher Rollins

PUBLIC

COMPLAINT CONTROL NUMBER: 14-CR-20210706084500

FACILITY NAME:	R.E.F.U.G.E.III, THE		FACILITY NUMBER:	015650058
ADMINISTRATOR:	KHEA GUMBS		FACILITY TYPE:	733
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	6	CENSUS: 3	DATE:	10/11/2021
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Khea Gumbs-Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Facility staff handled client in care in a rough manner
Facility staff used inappropriate form of discipline

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at REFUGE III and spoke with Khea Gumbs Administrator. The purpose of the inspection was to deliver the finding for the above complaint allegations.

During the course of investigating the allegation, LPA Rollins conducted confidential interviews with facility staff, clients, social workers and conducted clients file review. Confidential interviews reveal conflicting stories about facility staff handled client in care in a rough manner and facility staff used inappropriate form of discipline. Based on interviews and documentation there was not enough evidence to prove that facility staff handled client in care in a rough manner and facility staff used inappropriate form of discipline.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff handled client in care in a rough manner and facility staff used inappropriate form of discipline,therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Zaid Hakim	TELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: Christopher Rollins	TELEPHONE: (650) 465-0716
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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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