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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601953
Report Date: 04/02/2026
Date Signed: 04/03/2026 08:07:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2026 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260319120346
FACILITY NAME:KENSINGTON SIERRA MADRE, THEFACILITY NUMBER:
198601953
ADMINISTRATOR:CECILIA DEGRAFFFACILITY TYPE:
740
ADDRESS:245 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-5700
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:106CENSUS: 92DATE:
04/02/2026
UNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:C. C. De Graff, Executive Director TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Resident sustained an injury due to staff neglect or physical abuse
Staff did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced subsequent 10-Day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with the Executive Director, C. C. De Graff.

On 3/24/2026, the initial investigation visit was conducted. The investigation consisted of the following:

The investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA interviewed the Executive Director, Staff #1 (S1) to Staff #10 (S10), Resident #1 (R1) to Resident #10 (R10). LPA attempted to interview Resident #11 (R11) and Resident #12 (R12) but LPA unable to interview because R11 and R12 were unable to answer the questions. LPA interviewed Witness #1 (W1) over the phone. LPA also obtained documents from R1’s file such as the face sheet, Physician’s Report, Medical Notes, and other pertinent documents. LPA also obtained staff training and other pertinent documents.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
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 6
Control Number 28-AS-20260319120346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 04/02/2026
NARRATIVE
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On 4/1/2026, LPA Konishi emailed the Executive Director, Associate Executive Director and obtained pertinent documents.

During today's visit the investigation revealed the following: LPA interviewed the Executive Director and Associate Executive Director.

The investigation revealed the following in regards to the allegation: “Resident sustained an injury due to staff neglect or physical abuse,” it is alleged on 2/24/2026, at an outing while riding the facility bus, R1 was rubbing R1’s eyes with R1’s finger and the facility bus hit a bump which caused R1’s eye injury having a distinct black eye. CAT scan revealed that R1 was a victim of cerebral hemorrhage. LPA interviewed Executive Director, Associate Executive Director and nine (9) staff denied the allegation that stated there was no evidence that staff caused an injury to R1 on 2/24/2026 and that there were no witness of R1 sustaining the injury due to staff neglect or physical abuse. Six (6) staff stated that R1 did not report any pain on 2/24/2026. LPA interviewed R1 that denied the allegation stating that R1 cannot recall sustaining an eye injury on 2/24/2026. R1 could not recall reporting any pain on 2/24/2026. LPA interviewed one (1) resident that went on the outing of 2/24/2026 and denied the allegation stating not witnessing R1 or any resident sustain any injury. LPA interviewed an additional eight (8) residents that denied the allegation stating that the facility staff has not caused any resident’s injuries due to staff neglect or physical abuse. LPA attempted to interview an additional two (2) residents but LPA was unable to interview those two (2) residents since they were unable to answer the questions. LPA interviewed W1 that denied the allegation stating that R1 was not injured by staff neglect or physical abuse and additionally indicating that the staff have been very caring, supportive, and W1 doesn’t have any active concerns. Based on record review, LPA was unable to obtain any documents that indicated the direct cause to R1’s cerebral hemorrhage. However, LPA obtained medical notes dated 3/9/2026 of the diagnosis of R1’s cerebral hemorrhage and treatment. LPA reviewed staff training on Abuse, Neglect, and Exploitation in the Elder Care Setting. There was not enough supportive evidence to concur with the reported allegation.

Allegation: “Staff did not seek timely medical attention for a resident.” It is alleged that on 02/24/2026, R1 injured her eye and was not examined by a medical doctor for this injury. It is also alleged that on 02/27/2026, R1 had a distinct black right eye. On 02/28/2026, R1 was taken to the hospital in which the CAT scan revealed that R1 was a victim of cerebral hemorrhage. [Continue to LIC9099-C]
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20260319120346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 04/02/2026
NARRATIVE
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LPA interviewed the Executive Director, Associate Executive Director, LVN (Licensed Vocational Nurse) that denied the allegation stating that the injury observed around R1’s eye was minor and saw little to almost nothing around R1’s eye on 2/24/2026. However, the LVN stated that on 2/25/2026, LVN assessed the injury near her right eye, indicating that there was discoloration but no indication of a black eye. Executive Director stated that the facility chart by exception and notice until something is wrong. Executive Director also stated that the LVN and the facility care staff closely monitored R1’s condition for any changes in condition from 2/25/2026 to 2/28/2026 and there was no bruising and no visible injury that was observed and that R1 did not complain of any pain. The LVN cross reported the injury observed to R1’s responsible party on 2/25/2026. R1’s responsible party then took R1 to the hospital on 2/28/2026 for a previously scheduled CT scan which revealed the cerebral hemorrhage. However, there was no evidence obtained during the investigation that revealed that R1’s cerebral hemorrhage was a result of the injury sustained on 02/24/2026. LPA interviewed nine (9) residents that denied the allegation stating that staff seek timely medical attention for residents. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was held and a copy of this report was provided to the Executive Director, C. C. De Graff..
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2026 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260319120346

FACILITY NAME:KENSINGTON SIERRA MADRE, THEFACILITY NUMBER:
198601953
ADMINISTRATOR:CECILIA DEGRAFFFACILITY TYPE:
740
ADDRESS:245 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-5700
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:106CENSUS: 92DATE:
04/02/2026
UNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:C. C. De Graff, Executive Director TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff did not properly report an incident involving a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced subsequent 10-Day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with the Executive Director, C. C. De Graff.

On 3/24/2026, the initial investigation visit was conducted. The investigation consisted of the following:

The investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA interviewed the Executive Director, Staff #1 (S1) to Staff #10 (S10), Resident #1 (R1) to Resident #10 (R10). LPA attempted to interview Resident #11 (R11) and Resident #12 (R12) but LPA unable to interview because R11 and R12 were unable to answer the questions. LPA interviewed Witness #1 (W1) over the phone. LPA also obtained documents from R1’s file such as the face sheet, Physician’s Report, Medical Notes, and other pertinent documents. LPA also obtained staff training and other pertinent documents.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20260319120346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 04/02/2026
NARRATIVE
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On 4/1/2026, LPA Konishi emailed the Executive Director, Associate Executive Director and obtained pertinent documents.

During today's visit the investigation revealed the following: LPA interviewed the Executive Director and Associate Executive Director.

The investigation revealed the following in regards to the allegation: “Staff did not properly report an incident involving a resident.” It is alleged that R1’s responsible party was informed by staff on 2/26/2026, which is two days after R1 sustained an injury that occurred on 2/24/2026. LPA interviewed ten out of twelve residents denied the allegations stating that incidents are immediately notified their families and doctors. LPA attempted to interview two (2) out of twelve residents but LPA was unable to interview those two (2) residents since they were unable to answer the questions. LPA interviewed five (5) staff that could not corroborate nor deny the allegation since they are not involved in notifying the incident that occurred on 2/04/2026 to appropriate parties. LPA interviewed the Executive Director, Associate Executive Director, and an additional five (5) staff that denied the allegation stating that the that the injury of a scratch and discoloration near R1’s right eye was notified to R1’s responsible party on 2/25/2026. LPA obtained confirmation from obtaining documented exchange of communication dated 2/25/2026 between R1’s responsible party and the facility staff regarding the incident. However, the facility failed to notify licensing since there was no special incident report (SIR) sent from the facility to the department of R1’s eye injury. The Executive Director, Associate Executive Director and one (1) out of ten staff also stated that the SIR was not sent to licensing since the Associate Executive Director claimed that the severity of the injury was minimal. However, facility staff felt it was severe enough to notify R1’s responsible party. It was confirmed by the Associate Executive Director that neither of the SIR were not sent to Licensing. There is enough sufficient evidence to substantiate the allegation.
Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

An exit interview was held and the copy of the report and appeal rights were provided to the Executive Director, C. C. De Graff,.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20260319120346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/16/2026
Section Cited
CCR
80061(b)(1)(D)
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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
(1) Events reported shall include the following:
(D) Any injury to any client which requires medical treatment.

This requirement is not met as evidenced by:
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Executive Director will send Special Incident Report to Licensing by the POC due date.
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Based on interview and record review, The facility contacted Resident #1 (R1’s) responsible party on 2/25/2026 regarding the incident that occurred involving R1’s eye injury on 2/24/2026. However, the facility failed to notify licensing since there was no special incident report (SIR) sent from the facility to the department of R1’s eye injury. This poses a potential health, safety or personal rights risk to persons 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: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6