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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800335
Report Date: 10/28/2022
Date Signed: 10/29/2022 07:21:15 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20221026151959
FACILITY NAME:KIMS' CIRCLE B HOMEFACILITY NUMBER:
405800335
ADMINISTRATOR:MIRA & YONG KIMFACILITY TYPE:
735
ADDRESS:1430 CIRCLE B ROADTELEPHONE:
(805) 227-4649
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Mira Kim/LicenseeTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Licensee had inappropriate interactions with residents.
INVESTIGATION FINDINGS:
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 At 8:21am on 10/28/2022, Licensing Program Analyst (LPA) Mark Jeffries and Tri-Counties Regional Center (TCRC) Quality Assurance, Jeff Edler (QA) arrived at the facility to investigate the allegations to this complaint. QA and LPA conducted interviews of staff and clients. Based on interviews, admissions and time line LPA was able to deliver the following final findings to this complaint.
As to the allegation of, "Licensee had inappropriate interactions with the resident." it was discovered through interviews and admissions, of Staff 1-4, and Client 1 (C1), that on 10/20/2022, Licensee 1, Mira Kim (L1) had a medical emergency requiring an Emergency Room visit. Licensee 2 (L2) left the Emergency Room (ER) at approximately 9:30pm on 10/20/2022. According to interviews with L2, upon leaving the ER L2 was lost in the city of San Luis Obispo for an unknown amount of time. L2 stated that they were under duress from the hospital visit, the late hour in the evening, driving in the dark in unfailiar area and general tiredness was why L2 got lost. L2 arrived back at the facility at approximately 10:30pm to relieve the S2 for overnight staffing.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
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 5
Control Number 29-AS-20221026151959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: KIMS' CIRCLE B HOME
FACILITY NUMBER: 405800335
VISIT DATE: 10/28/2022
NARRATIVE
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When L2 arrived at the facility at approximately 10:30pm the facility lights were off and the facility was dark, confirmed in interviews with S2 and L2. L2 stated they were having difficulties navigating through the dark facility and stumbled into the room that L2 thought was the staff over night room but was in fact C1's room. L2 stumbled into the back frame of the bed and accidentally touched C1's foot as L2 was catching himself from a fall that resulted in bumping into the bed frame. LPA noted that the bed frame in C1's room is near the threshold of C1's bedroom door. L2 stated that they realized it was the wrong room when C1 stated, "Hey that's my foot" L2 said, "Sorry" then left C1's room, according to L2. Additionally, In an interview with C1, C1 stated that L2 came into their room at night, touched C1's foot, C1 stated, Hey, that's my foot" then L2 apologized by saying, "sorry". then L2 left that room. L2 stated that they further stumbled around the facility until they found the overnight staff bedroom. Based on interviews, and admissions, there is not enough evidence at this time to support the allegation of, "Licensee had inappropriate interactions with residents." and is unsubstantiated at this time.

Exit interview, report signed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20221026151959

FACILITY NAME:KIMS' CIRCLE B HOMEFACILITY NUMBER:
405800335
ADMINISTRATOR:MIRA & YONG KIMFACILITY TYPE:
735
ADDRESS:1430 CIRCLE B ROADTELEPHONE:
(805) 227-4649
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Mira Kim/LicenseeTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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2
3
4
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8
9
Licensee yelled at resident.
INVESTIGATION FINDINGS:
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13
 At 8:21am on 10/28/2022, Licensing Program Analyst (LPA) Mark Jeffries and Tri-Counties Regional Center (TCRC) Quality Assurance, Jeff Edler (QA) arrived at the facility to investigate the allegations to this complaint. QA and LPA conducted interviews of staff and clients. Based on interviews, admissions and time line LPA was able to deliver the following final findings to this complaint.
As to the allegation of, "Licensee yelled at resident." it was discovered through interviews and admission that on 10/21/2022 and 10/22/2022 Licensee Mira Kim (L1) admitted to raising their voice and yelling at resident C1 and S1. In an interview by phone on 10/24/2022 and an in-person interview on 10/27/2022 L1, stated that they were upset at S1 and C1 because S1 had failed to notify L1 of the accidental touching of C1 on night of 10/20/2022. L1 stated that they yelled at S1 about not trusting S1 to report the incident to L1 and trust issues, additionally, L1 stated they were sorry that they yelled at C1 because L1 was going through a difficulty medical condition episode, the context of the yelling was not specified by L1. In an interview with S2, S2 stated that they observed L1 yelling at S1 and C1 on the morning of 10/22/2022 while doing a medication training. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20221026151959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: KIMS' CIRCLE B HOME
FACILITY NUMBER: 405800335
VISIT DATE: 10/28/2022
NARRATIVE
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In interviews with S1 and C1 this was also confirmed that L1 was yelling for the same reason as the episode of yelling from L1 on the prior day 10/21/2022. Based on interviews, and admitting, the allegation of, Licensee yelled at resident." is substantiated at this time. Citation and Plan of Correction issued.


Exit interview, report read, citation issued, and report signed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20221026151959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KIMS' CIRCLE B HOME
FACILITY NUMBER: 405800335
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)... each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met
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Licensee will have 1 hour of Personal Rights training with staff completed by 11/14/2022. Proof will be submitted to LPA by 11/14/2022. by email. mark.jeffries@dss.ca.gov
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by evidence of: Licensee admitting to yelling at client in care, which poses a potential risk to client 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: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5