<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601953
Report Date: 05/14/2026
Date Signed: 05/14/2026 02:03:53 PM

Substantiated


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: 91DATE:
05/14/2026
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Daniel Orozco, Associate Executive DirectorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly report an incident involving a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This report supersedes report dated 04/02/2026. The reason this report is being superseded is to correct the regulation that was cited and to include additional information. The findings will remain the same.**

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 Associate Executive Director, Daniel Orozco.

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. [Continue to LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
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 4
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: 05/14/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

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 a 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. LPA obtained progress notes dated 02/25/2026 which document R1’s eye injury. Facility did not take pictures of R1’s injury nor was there any documentation completed by facility staff indicating that a body assessment was completed for R1 after noticing this 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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 05/14/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Additionally, R1 was hospitalized on 03/06/2026 through 03/09/2026. During this hospitalization, R1 was diagnosed with traumatic subdural hemorrhage. LPA obtained this documentation during the investigation from R1’s file. The facility did not submit a Special Incident Report (SIR) for R1 regarding this hospitalization. The facility has a responsibility to report any serious injuries involving residents to the Department. Therefore there is enough sufficent evidence to substantiate.

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 Associate Executive Director, Daniel Orozco.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 05/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2026
Section Cited
CCR
87211(a)(1)(B)
1
2
3
4
5
6
7
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) 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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Executive Director will send Special Incident Report (SIR) involving R1’s hospitalization to the LPA by the POC due date.
8
9
10
11
12
13
14
Based on interview and record review, the facility failed to submit a Special Incident Report (SIR) for R1’s hospitalization that occurred between 03/06/2026 to 03/09/2026. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4