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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601716
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:41:33 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
06/18/2024 and conducted by Evaluator Erik Zaragoza
COMPLAINT CONTROL NUMBER: 28-AS-20240618110757
FACILITY NAME:CHOICES R US - MIGUELFACILITY NUMBER:
198601716
ADMINISTRATOR:CARDENAS, GILBERTFACILITY TYPE:
735
ADDRESS:3951 MIGUEL AVETELEPHONE:
(562) 801-3061
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:4CENSUS: 4DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Sami Abdulsemiu - CaregiverTIME COMPLETED:
03:56 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident resulting in injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analsyts (LPAs) Erik Zaragoza conducted an unannounced initial complaint visit in regards to the allegation listed above. LPA explained the purpose of the visit to Sami Abdulsemiu, caregiver for the facility, and was granted entrance. Administrator Gilbert Cardenas was informed of the visit by phone call.

The investigation consisted of the following: LPAs Erik Zaragoza conducted a tour of the facility and interviewed Clients #1 - 4 (C1 - C4), Staff #1 - 3 (S1 - S3). LPA also request that administrator Gilbert Cardenas email LPA the Physician's Report, Appraisal, and FACE Sheet from Client #1 (C1), along with the current staff and client rosters.

Due to insufficient information available at this time, the above allegations needs further investigation.

Exit interview conducted with Sami Abdulsemiu, and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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