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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601953
Report Date: 06/15/2026
Date Signed: 06/15/2026 04:46:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/03/2026 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260603115213
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:
06/15/2026
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Deseree Suyat - Director of NursingTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff allowed unauthorized individuals to be present while residents were in care.
Staff's personal pet poses as a risk to the residents while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Director of Nursing Deseree Suyat explained the purpose of the visit.

The investigation consisted of the following:
On 6/12/26 LPA obtained copies of the Staff and Resident rosters, copies of the Pet Policy and Vitiation Policy were provided, toured facility, and conducted interviews with 4 Staff (S1-S4) and 10 Residents (R1-R10), 2 of which had visitors that were also interviewed during visit (W1-W2).
During todays visit 6/15/26, LPA reviewed documents, typed report and delivered findings on the reported allegations.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
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 2
Control Number 28-AS-20260603115213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 06/15/2026
NARRATIVE
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The investigation revealed the following:
Allegation: Staff allowed unauthorized individuals to be present while residents were in care.
It is alleged that facility staff have their children running throughout the common areas of the facility, have unrestricted access to resident areas while engaging in behavior that could be disruptive to residents and visitors. LPA interviewed 4 staff and each denied the allegation, staff stated that although staff members do sometimes bring their children to the office, they are well behaved and always have a staff member with them when they assist with games/activities. S1 and S2 stated that there are children volunteers that visit the facility to bring joy to the residents, they just had a visit from the children, it was superhero day, both children/residents wore capes and were having fun in a controlled/supervised environment. LPA interviewed 10 residents, each denied the allegation, residents stated they see children at the facility and have never felt the children behave in a disruptive manner. Interviews with 2 visitors/family members of residents revealed they visit regularly and have never seen the children that visit be disruptive in any way and said they also enjoyed seeing the children and the happiness they bring to the residents.
Allegation: Staff's personal pet poses as a risk to the residents while in care.
It is alleged that the facility has a dog moving near residents, and it appeared that at least one resident nearly tripped as the dog passed by. LPA interviewed 5 staff and each denied the allegation, staff stated that the facility is a pet friendly environment, some residents have pets that are kept in their units/rooms but if they take them out for a walk, the pets are on a leash and being assisted by staff if needed. Staff stated there is not a facility pet, however, visitors and staff will bring their pets to the facility to allow pet therapy, there is a designated area with a puppy pen that is controlled for the pets and residents safety; residents that wish to interact with the pets are able to go to the designated area and pet the animals with a staff present to assist. LPA interviewed 10 residents, 9 out of 10 residents denied the allegation and stated they have never seen any pets roaming around the facility without a leash. R1-R3 who have pets at the facility stated their pets stay in their rooms, R3 stated that if they need to have their dog walked they make sure they are on a leash and staff assist with walking their dog. Residents stated this has never been a concern of theirs and have never tripped over any of the pets. Interviews with 2 visitors/family members of residents revealed they visit regularly, have never seen any dogs or pets walking about the facility freely, the pets are always on a leash with supervision, and they have never had any concerns of their family being injured by tripping over the pets. LPA toured the activity room and observed the doggy/puppy pen that houses the pets when they are there (there were no pets in the pen during visit).
Based on statements and interviews conducted with staff/residents, review of policies and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
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