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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601711
Report Date: 03/27/2023
Date Signed: 03/28/2023 04:40:09 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230320084011
FACILITY NAME:HAMUD RESIDENTIAL HOME, THEFACILITY NUMBER:
198601711
ADMINISTRATOR:NORMA HAMUDFACILITY TYPE:
735
ADDRESS:2517 EAST 219TH PLACETELEPHONE:
(424) 264-5186
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY:6CENSUS: 4DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:NORMA HAMUDTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff are not providing proper maintenance of resident's medical device.
INVESTIGATION FINDINGS:
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On 3/27/23, Licensing Program Analyst (LPA), Lourdes Montoya conducted a 10-day complaint visit. Upon arrival, LPA met with Administrator Norma Hamud and explained the purpose of today's visit.

During this investigation LPA conducted the initial 10-day complaint visit and interviewed (5) staff. LPA attempted to interview all four clients, but three out of four clients are non-verbal and the other client left the facility for a walk. LPA obtained a copy of Client #1's service records.

The investigation revealed

Allegation: Facility staff are not providing proper maintenance of resident's medical device.

It was reported that Client #1’s G-tube is leaking, and water is not being replaced. LPA interviewed five staff (S1-S5) during the visit. Four staff (S1-S4) stated Client #1 uses a G-tube for supplements and medications. Client #1 does not use the G-tube for feeding with food and hydration. S1-S4 revealed Client #1’s G-tube is properly working, and it has the required water level.

REPORT CONTINUED IN LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 11-AS-20230320084011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAMUD RESIDENTIAL HOME, THE
FACILITY NUMBER: 198601711
VISIT DATE: 03/27/2023
NARRATIVE
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S1-S4 stated the G-tube sometimes leaks a small of the supplements or liquid when Client #1 walks around restlessly after taking the supplement through the G-tube. Per LPA's review of Client #1’s medication administration records (MAR) and interview with four staff (S1-S4), an adhesive cream is applied to the G-tube three times a day and as needed after cleaning the G-tube. The staff (S1-S4) stated G-tube water can only be replaced by the facility nurse, Client #1’s doctor or the father. S2-S4 stated they are trained to assist Client #1 with the G-tube. During the visit, LPA observed the G-tube is in good condition. Based on observations, record reviews and interviews, there is no sufficient evidence to corroborate the above 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 deemed unsubstantiated.

Unrelated deficiencies cited in a separate case management.

An exit interview was conducted and a copy of this report was provided to Administrator Norma Hamud.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230320084011

FACILITY NAME:HAMUD RESIDENTIAL HOME, THEFACILITY NUMBER:
198601711
ADMINISTRATOR:NORMA HAMUDFACILITY TYPE:
735
ADDRESS:2517 EAST 219TH PLACETELEPHONE:
(424) 264-5186
CITY:LONG BEACHSTATE: CAZIP CODE:
90810
CAPACITY:6CENSUS: 4DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:NORMA HAMUDTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
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Facility staff are not properly managing resident's supplements.
INVESTIGATION FINDINGS:
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On 3/27/23, Licensing Program Analyst (LPA), Lourdes Montoya conducted a 10-day complaint visit. Upon arrival, LPA met with Administrator Norma Hamud and explained the purpose of today's visit.

During this investigation, LPA conducted an initial 10-day complaint visit and interviewed five (5) staff. LPA attempted to interview all four clients, but three out of four clients are non-verbal and the other client left the facility for a walk. LPA obtained a copy of Client #1's service records.

The investigation revealed:

Facility staff are not properly managing resident's supplements.

It was reported that facility staff has been forgetting to pack one of Client #1’s supplements when going on home visits. LPA interviewed five staff (S1-S5) during the visit. Three staff (S1-S3) admitted facility

REPORT CONTINUED IN LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 11-AS-20230320084011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAMUD RESIDENTIAL HOME, THE
FACILITY NUMBER: 198601711
VISIT DATE: 03/27/2023
NARRATIVE
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staff (S3) forgot to pack Client #1’ supplements when the father picked up the client on March 10, 2023 and March 17, 2023. S1 explained S3 packed everything else that Client #1 normally would bring home but S1 overlooked to pack supplements because S1 was simultaneously Client #1 was having a tantrum. S1 stated the father regularly picks up Client #1 on Fridays and notifies the administrator about an hour prior to coming to the facility. Based on LPA’s observations, interviews and record review, there is sufficient evidence to corroborate the above the allegation.

Based on the information gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 are being cited on the attached LIC9099D.

Exit interview conducted with Administrator Norma Hamud, a copy of this report was provided and Appeal Rights were given.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230320084011
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAMUD RESIDENTIAL HOME, THE
FACILITY NUMBER: 198601711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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The administrator shall provide licensing an updated Restricted Health Condition Care Plan showing necessary steps or procedures in assisting client with supplements. Administrator shall submit the POC via email to CCLD to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on information gathered, S3 packed everything else that Client #1 normally would bring home but S3 overlooked to pack supplements on two occassions. S1 stated the father regularly picks up Client #1 on Fridays and notifies the administrator about an hour prior to coming to the facility. This poses a potential risk to health, safety or personal rights to clients 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5