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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320304
Report Date: 03/19/2026
Date Signed: 03/19/2026 01:30:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2026 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260220083158
FACILITY NAME:KINAH MAE HOME LLCFACILITY NUMBER:
198320304
ADMINISTRATOR:WHITFORD, WALKIRIAFACILITY TYPE:
740
ADDRESS:1420 W. 186TH ST.TELEPHONE:
(310) 720-7080
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY:6CENSUS: 5DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Renette De La Cruz (Administrator)TIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff do not ensure that resident's toileting needs are being met
Staff mismanaged resident’s medication
INVESTIGATION FINDINGS:
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On 03/19/2026 at 12:05pm, Licensing Program Analyst (LPA) Brown conducted a subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Renette De La Cruz (Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 02/24/2026 at 10:15am, LPA interviewed Administrator (A1), Staff (S1-S4), and Residents (R2-R5) and Resident 1 (R1) between the hours of 12:15pm - 12:19pm. LPA received received the following documents: Resident Roster (received on 02/24/2026, Resident records such as LIC 601 Personnel Record (for R1-R4), LIC 602: Physician Report (for R1-R4), LIC 603: Pre-Placement Appraisal (for R4), LIC 604: Admission Agreement (for R1 - R4), Medication Administration Record (for R1-R4 - dated 01/2026 - 02/2026), Communication Logs (12/02/2025 - 02/20/2026), Staff Schedule, Eviction Notice Letter ( for R1 dated 02/19/2026).

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
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 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2026 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260220083158

FACILITY NAME:KINAH MAE HOME LLCFACILITY NUMBER:
198320304
ADMINISTRATOR:WHITFORD, WALKIRIAFACILITY TYPE:
740
ADDRESS:1420 W. 186TH ST.TELEPHONE:
(310) 720-7080
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY:6CENSUS: 6DATE:
03/19/2026
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Renette De La Cruz (Administrator).TIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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On 03/19/2026 at 12:05, Licensing Program Analyst (LPA) Brown conducted a subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Renette De La Cruz (Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 02/24/2026 at 10:15am, LPA interviewed Administrator (A1), Staff (S1-S4), and Residents (R2-R5) and Resident 1 (R1) between the hours of 12:15pm - 12:19pm on 03/19/2026. LPA received the following documents: Resident Roster (received on 02/24/2026, Resident records such as LIC 601 Personnel Record (for R1-R4), LIC 602: Physician Report (for R1-R4), LIC 603: Pre-Placement Appraisal (for R4), LIC 604: Admission Agreement (for R1 - R4), Medication Administration Record (for R1-R4 - dated 01/2026 - 02/2026), Communication Logs (12/02/2025 - 02/20/2026), Staff Schedule, and Eviction Notice Letter (for R1 dated 02/19/2026).

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
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 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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Allegation: Unlawful eviction
It was alleged that the facility unlawfully issued a 30-day eviction notice to a resident. On 02/18/2026, a text message stated the resident's voice had become loud and other residents had complained about the resident's behavior. As a result, the resident was given a 30-day notice via text.

On 02/24/2026 at 10:48am -11:28am, LPA interviewed A1 regarding the allegation. A1 acknowledge the allegation and stated a 30-day notice was issued to Resident 1 (R1). A1 stated the reason R1 would receive a 30-day notice at this facility is because the other residents have complained about R1's behavior such as yelling, inappropriately touching female staff, and occasionally exposing themselves every night. A1 stated the facility's policy on addressing resident behavior concerns before issuing an eviction notice is to notify the family by phone to express the concerns of their family member. A1 stated all the residents have complained about the noise and behavioral issues with the resident. A1 mentioned the facility accommodates residents with dementia or Parkinson's disease who may exhibit behavioral changes by getting a reassessment from the resident's physician, and the administrator will express the resident's behavior to the doctor and ask if there is a medication to help assist with the behavioral changes.

On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff were aware of the allegation and stated a resident received an eviction notice recently. Staff stated that the other residents and their families have complained about the R1's behavior at night, particularly R3 who share a room with R1 and the other residents who live at the facility. Staff mentioned the facility has not evicted a resident because of the family raising concerns about care. Staff indicated they believe Community Care Licensing was informed about the eviction.

On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 3 of 5 residents were aware of the allegation and stated they know of a resident, who have been asked to leave the facility, everyone knows the situation and it affects everyone, and they have heard staff talk about evicting someone. 2 of 5 residents were unaware of the allegation and stated they do not know of any residents who have been asked to leave the facility and have not heard staff talk about evicting someone. Residents stated they feel safe talking to staff about problems or concerns and do not know if anyone has been told to leave because their family complained about care.

Report continues on LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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On 03/17/2026, between the hours of 10:00am – 11:00am, LPA conducted a records review and observed the following: A Notice Letter (signed and dated on 02/19/2026) and a copy of the US Postal Service Certified Mail Receipt with the postmark date of 02/21/2026 with an estimated delivery date to R1's responsible party on 02/24/2026. The eviction notice issued to the R1's responsible party is not in compliance with Title 22 regulation and is missing the following information: 87224 (a) – (i) Eviction Procedures. Also a copy of the notice letter was not sent to the Department within 5 days of issuance.

Substantiated: Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights.

Exit interview conducted with Renette De La Cruz (Administrator) and a copy 87244 (a) - (i) Eviction Procedures was provided with a copy of this report and Appeal Rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2026
Section Cited
CCR
87224(a)-(i)
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(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). . This requirement was not met by: Based on interview, observation & records
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The licensee will issue a formal dismissal of the eviction notice to R1’s responsible parties and the Department of Social Services, Community Care Licensing Division (CCLD).
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review the licensee issued an eviction notice to Resident's 1 (R1) responsible parties which is not in complliance with Title 22 regulations. This violation poses a potential health and safety or personal rights risk to residents in care.
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Proof of correction will be submitted to the CCLD/El Segundo ASC Office via fax at 424-544-1016 (Attn: Zina Brown) or via email at zina.brown@dss.ca.gov by the POC 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: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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 Allegation: Staff handled resident in a rough manner
It was alleged that facility staff handled a resident in a rough manner. When a specific staff member is on duty, the staff member handles the resident roughly, such as pushing the resident onto the bed without waiting for the resident to position properly, and placing covers over the resident while the resident was lying diagonally. The staff member is abrasive and rough when removing the resident's clothes and handling the resident, causing physical discomfort. The resident has told the staff member that it hurts, but the staff member continues to be rough.

On 02/24/2026 at 10:48am -11:28am, LPA interviewed A1 regarding the allegation. A1 acknowledge the allegation and stated receiving complaints about staff handling residents roughly from the resident's family. A1 stated staff have completed Safety in the Home: Fall Prevention training on file. A1 stated the facility's policy when a resident or family reports staff being rough or causing discomfort is to have a discussion with the caregivers. A1 denied receiving complaints about a specific staff member's care techniques and stated the residents love the caregivers.

On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff denied the allegation and stated they have not handled any resident roughly and have not witnessed other staff do so. Also staff mentioned all residents are treated with proper care. Staff indicated one of the resident's family member advise for the staff to be more careful with their loved one.

On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 1 of 5 staff confirmed the allegation and stated staff have been rough and hurt them while helping them. 4 of 5 residents denied the allegation and stated staff help them gently when getting them dressed or into bed. Also no staff member has been rough with them or hurt them while helping them, and they have not seen staff be rough with other residents.

On 03/17/2026, between the hours of 4:00pm - 4:05pm, LPA conducted a records review & observed the following: The department did not received any LIC 624 Unusual Incident/Injury Report in regards to a staff handling residents in a rough manner.

Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Report continues on LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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Allegation: Staff do not ensure that resident's toileting needs are being met
It was alleged that facility staff do not ensure that the resident's toileting needs are being met. Between the hours of 10:00pm - 4:00am, the resident's call button often goes unanswered for over an hour. During these times, the resident has had to call their responsible party at home, and the responsible party then contacts the caregiver by phone to request assistance. The staff do not always turn on the resident's bed alarm. Also its been stated the resident once needed to urinate, but the urinal was full. The resident got up to use the restroom, fell, and hit the resident's knee in the process.

On 02/24/2026 at 10:48am - 11:28am, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and stated receiving complaints about delayed responses to call buttons from the resident's family member. A1 stated the facility's policy for responding to call buttons is to attend to the call button right away. If the caregiver is busy, the caregiver will explain being busy with another resident and will help as soon as possible. In the event of an emergency, the caregiver will prioritize the emergency first. A1 stated staff are expected to respond right away when a resident calls for assistance. A1 mentioned bed alarms and motion alarms are used for residents who are fall risks and staff ensure the bed alarm is always on. A1 stated the procedures in place for nighttime toileting assistance are upon request from the resident, staff will assist the resident with toileting in the night. Also, staff conduct random checks during the night, especially for dementia residents, by taking the resident to the bathroom or changing diapers. A1 stated one time a caregiver explained to the resident that the caregiver was assisting another resident who had vomited and told the resident once the caregiver was done assisting that resident, the caregiver would help the resident.

On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff denied the allegation. The staff mentioned responding to the call light button promptly while conducting nighttime routines to assist the residents with toileting as needed.

On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 1 of 5 residents confirmed the allegation and mentioned when they use the call button staff does not come to help and waits a long time (about 10 minutes) for help going to the bathroom. The resident who confirmed the allegation also stated that staff does not help right away when needing to use the bathroom at night. 2 of 5 residents denied the allegation and mentioned staff respond promptly with no significant delay with toileting. 2 of 5 residents did not confirm nor deny the allegation as one of the resident does not go to the bathroom due to wearing diapers and does not have to wait a long time to be changed. The other resident stated rather not saying how long having to wait on staff to come when calling for help but stated it depends if there is a need to use the bathroom at night that staff member are pretty much right away.Residents stated that staff generally respond to call buttons within minutes, prioritizing emergencies and explaining any delays. During the night, staff conduct checks every 1–2 hours, set bed alarms, and assist with toileting. Although there are infrequent complaints regarding wait times for bathroom assistance, residents agreed that help usually arrives promptly.

Report continues on LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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On 03/17/2026 between the hours of 1:25pm - 1:30pm, LPA conducted a records review and observed the following: On 05/17/2025 the facility had record of an In-Service Education on Personal Hygiene with 3 staff in attendance for three hours between the hours of 9am - 12 noon. According to Resident 1 (R1) LIC 602 Physician's Report for Residential Care Facilities for the Elderly (RCFE) states on page 4 of 6 under section 15. Capacity for Self Care d. Able to Care for Own Toileting Needs is checked yes which explain slow but able occasional. In the R1's admission agreement on page 77, for 9 Assistance with personal activities of daily living as follows: toileting is checked off. On LIC 625 Appraisal/Needs & Service Plan in the Background Information it states R1 requires assistance with toileting. Also the department did not received any LIC 624 Unusual Incident/Injury Report in regards staff not meeting the toileting needs of the residents

Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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Allegation: Staff mismanaged resident's medication
It was alleged that facility staff mismanaged the resident's medication. About three weeks ago, the resident was given the wrong medication. When the resident questioned the staff, they tried to make the resident take it, accusing the resident of not knowing the medications. The resident became loud and refused the medication until staff checked. Staff later confirmed they had the medication wrong but gave the resident the right medications.

On 02/24/2026 at 10:48am -11:28am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated there have not been any recent medication errors reported at this facility. A1 stated the facility's procedure for administering medications to residents is to give the medication to the resident as prescribed by the doctor. A1 stated if staff realize they may have given the wrong medication to a resident, the facility would call the doctor and report to licensing, but stated this has not happened yet. A1 stated staff verify medications before administering them to residents by checking the MAR and matching the medication to ensure it is correct before administering the medication to the resident.

On 02/24/2026 between the hours of 11:34am -12:26pm, LPA conducted 4 staff interviews regarding the allegation. 4 of 4 staff denied the allegation, stating they have never administered the wrong medication. They explained their verification process includes confirming the resident’s name and dosage, double- and triple-checking before administration, and discussing the medication’s purpose with the resident. Furthermore, staff ensure medications are taken in their presence, explain prescriptions when questioned, and contact the administrator or doctor if necessary. Any medication errors would be reported immediately to the administrator.

On 02/24/2026 between the hours of 10:24am -1:22pm & on 03/19/2026 between the hours of 12:15pm - 12:19pm, LPA conducted 5 resident interviews regarding the allegation. 1 of 5 resident confirmed the allegation and stated staff do not give medications every day. 1 out of 5 residents did not confirm nor deny the allegation and mentioned not feeling safe when taking their medication given by staff which is not everyday. However the resident indicated staff does listen and check when the resident has question about their medication and has not been given the wrong medication.
3 of 5 residents denied the allegation and stated staff give them their medications every day. They noted that staff have never given them the wrong medication and always listen if they have questions. Ultimately, they feel safe taking the medications staff provide.

Report continues on LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 11-AS-20260220083158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: KINAH MAE HOME LLC
FACILITY NUMBER: 198320304
VISIT DATE: 03/19/2026
NARRATIVE
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On 03/17/2026 between the hours of 1:25pm - 1:30pm, LPA conducted a records review of the Medication Administration Record (MAR) for January 1, 2026 - February 25, 2026 and observed for Resident 1 (R1) that  all medication as prescribed were administered by proof of staff initial for Aspirin 8mg, Famotidine 10mg (for heartburn), Carbidopamine (for Parkinson's Disease), Magnesium Citrate 250mg, Gingko Biloba (for Cognitive Function), Memantine (10 mg), Epadel, Zetia 10mg (for cholesterol), Prevastatin (for cholesterol), Refresh, Diclofenac (PRN). Also, upon further review, the Department has not record of an LIC 624 Unusual Incident/Injury Report from the facility in regards to R2 being given the incorrect medication with no proof of staff later confirming resident was give wrong medication but gave the resident the correct medication. On 02/18/2025, the facility has record of an in-service education for Medication Administration with 6 staff in attendance on 02/18/2025 between the hours of 3pm - 4pm. On 02/10/2025, S2 completed 8 hours of Medication Training during the Annual Staff Training (20 Required Hours - dated 02/10/2025) . On LIC 625 Appraisal/Needs & Service Plan in the Background Information it states R1 requires full medication management assistance.

Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Renette De La Cruz (Administrator). and a copy of this report was provided
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC9099 (FAS) - (06/04)
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