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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006299
Report Date: 01/08/2026
Date Signed: 01/08/2026 05:54:07 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240729203119
FACILITY NAME:KEEN HOME HARVARDFACILITY NUMBER:
306006299
ADMINISTRATOR:HERBAS, ADRIENFACILITY TYPE:
740
ADDRESS:5112 HARVARD AVETELEPHONE:
(562) 438-5336
CITY:WESTMINISTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 6DATE:
01/08/2026
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Latoya JohnsonTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not notify resident's responsible party of incident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Administrator Latoya Johnson and explained the reason for the visit. The investigation into the allegation, staff did not notify resident's responsible party of incident in a timely manner, revealed the following. It was reported that after Resident 1 (R1) fell on June 16, 2024 the responsible party/power of attorney (POA) was not notified by facility staff until 4 to 5 hours after the fall. According to the incident report submitted to the Agency (Community Care Licensing) on June 17, 2024, R1 fell around 4:00 am on June 16, 2024. Staff called 911 and R1 was transported to the hospital, treated and returned to the facility the same day around 7:00 am. The Licensee reported that they were immediately called by Staff 1 (S1) after they called 911 and they (Licensee) called R1's responsible party/power of attorney (POA) to get permission to send R1 to the hospital. The POA agreed and R1 was transported to the hospital by paramedics. The Licensee reported that they contacted R1's responsible party/power of attorney (POA) around 10:00 am to inform them R1 had returned to the facility. R1's responsible party/power of attorney (POA) verified this report.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
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 5
Control Number 22-AS-20240729203119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KEEN HOME HARVARD
FACILITY NUMBER: 306006299
VISIT DATE: 01/08/2026
NARRATIVE
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California Code of Regulation (CCR), Title 22, Division 6, 87211(a)(1) states, "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below." Falling and being injured qualify under, CCR 87211(a)(1)(D), "Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." R1's responsible party/power of attorney (POA) verified they received a report and were called twice regarding this incident. R1's responsible party/power of attorney (POA) was notified the same day as the reported incident, therefore the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with the Administrator and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2024 and conducted by Evaluator Joseph Alejandre
COMPLAINT CONTROL NUMBER: 22-AS-20240729203119

FACILITY NAME:KEEN HOME HARVARDFACILITY NUMBER:
306006299
ADMINISTRATOR:HERBAS, ADRIENFACILITY TYPE:
740
ADDRESS:5112 HARVARD AVETELEPHONE:
(562) 438-5336
CITY:WESTMINISTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 6DATE:
01/08/2026
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Latoya JohnsonTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
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9
Facility staff did not seek medical attention for resident in a timely manner.
Staff did not address resident's change in condition.
Resident sustained multiple falls resulting in injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Latoya Johnson and explained the reason for the visit. The investigation into the allegation, facility staff did not seek medical attention for resident in a timely manner, revealed the following. It was reported that R1 suffered a fall on June 16, 2024 around 4:00 am and staff did not call 911 in a timely manner. During the initial 10-day visit R1 was asleep and could not be interviewed. R1 has been diagnosed with Dementia. R1 passed away on August 11, 2025. A review of records shows R1's fall on June 16, 2024 was reported to the Agency (Community Care Licensing) on a special incident report (SIR/LIC 624), received on June 17, 2024. According to the LIC 624 Staff 1 (S1) was assiting R1 around 4:00 am and R1's knee gave out and they fell pulling their walker toward their face and the walker hit their nose causing an injury and bruising. S1 also fell. S1 stated they fell with the resident and immediately called 911and then called the Licensee who called R1's responsible party/power of attorney who agreed R1 should be transferred to the hospital. S1 reported they called 911 right after the fall and got a clean cloth to stop the bleeding from R1's nose.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
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 22-AS-20240729203119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KEEN HOME HARVARD
FACILITY NUMBER: 306006299
VISIT DATE: 01/08/2026
NARRATIVE
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S1 reported that paramedics arrived a few minutes later and transported R1 to the hospital. S1 reported that R1 returned to the facility around 7:00 am the same day. R1's responsible party/power of attorney reported they were notified right after the fall occurred and around 10:00 am after R1 returned to the facility. Staff 2 (S2) reported they arrived at the facility after the incident. S1 reported there were no other witnesses to the incident. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, resident sustained multiple falls resulting in injury while in care, revealed the following. R1 moved into the facility on April 22, 2024. R1 was diagnosed with Dementia, Coronary Artery Disease, Severe Arthritis and was non-ambulatory. R1 was identified as a fall risk when they moved into the facility. R1's care plan calls for R1 to be checked every 2 hours and to be assisted with all transfers and to be escorted whenever moving. R1 used a walker and a wheelchair. R1 suffered falls on May 10, 2024, May 12, 2024, June 16, 2024 and June 30, 2024. All incidents were reported to the Agency (Community Care Licensing) and R1's responsible party. Both falls in May 2024 resulted in no injuries and no report of pain or discomfort. R1 fell on June 16, 2024. Staff 1 (S1) was assisting R1 around 4:00 am and R1's knee gave out and both R1 and S1 fell. The walker hit R1 on their face causing an injury to their nose and bruising around their eyes. S1 called 911 and R1 was transported to the hospital, treated and released the same day. The Licensee scheduled an appointment for R1 with a medical professional on June 17, 2024 which resulted in R1 being treated for a urinary tract infection (UTI). R1 fell on June 30, 2024. S1 reported that around 4:00 am R1's bed alarm went off and they went to R1's room and R1 was found on the floor next to their bed. S1 reported that they called 911 because R1 reported pain. Paramedics arrived at the facility and assessed R1 and reported no injuries and reported there was no reason to transport R1 to the hospital. Staff 2 (S2) reported that X-rays were ordered on June 30, 2024 for R1 as a precaution and the results came back negative. After the fall on May 10, 2024, the facility ordered a pad to be placed next to R1's bed in case R1 fell out of bed. 3 out of 3 caregivers and the Licensee reported that R1 was given increased checks every hour after the fall on May 10, 2024. The Licensee reported that after the fall on May 12, 2024, a pressure alarm pad was placed on R1's bed to notify them if R1 was out of bed and R1 was encouraged to call for assistance using their pendant anytime they wanted help. After the fall on June 16, 2024, the facility consulted with R1's responsible party and their physician. R1 was prescribed a new bed that could be lowered close to the floor to help minimize falls.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240729203119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: KEEN HOME HARVARD
FACILITY NUMBER: 306006299
VISIT DATE: 01/08/2026
NARRATIVE
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The bed did not arrive until July 2024. The Licensee reported they recommended a one on one caregiver to R1's responsible party after the fall on June 16, 2024 but they declined. The Licensee reported that they informed all staff that one caregiver should always be sitting next to or around R1 when they are awake. 3 out of 3 caregivers verified this information. R1's fall on June 30, 2024 happened around 4:00 am and staff was notified by the bed alarm and attempted to assist R1. The facility was constantly addressing R1's needs and adding preventative measures to mitigate R1's fall risk. There were no more falls reported for R1 after June 30, 2024. R1's responsible party reported that the facility did everything they could to prevent R1 from falling. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff did not address resident's change in condition, revealed the following. It was reported that R1's fall on June 16, 2024 was due to a change in condition, possibly due to their medication. Other than falling no details about the change in condition were provided. No details were provided as to which medication changes or specific medications contributed to R1 falling on June 16, 2024. 3 out of 3 caregivers and the Licensee reported that R1 had always had wandering behaviors, aggressive behaviors, refusing medications and was a fall risk since they moved in the facility on April 22, 2024. 3 out of 3 caregivers and the Licensee reported that R1 did not display any new behaviors in June or July 2024. A review of facility records show, after R1's fall on June 16, 2024, the Licensee scheduled a home health visit with a Nurse Practitioner on June 17, 2024. After the visit tests were conducted and R1 was diagnosed with a urinary tract infection (UTI). R1's physician ordered antibiotics to treat R1. After the fall the facility had R1 assessed by a medical professional who addressed R1's change in condition. There is no evidence to support the allegation therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5