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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602399
Report Date: 02/18/2023
Date Signed: 02/18/2023 01:28:48 PM

Document Has Been Signed on 02/18/2023 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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:SAMOLINE GUEST HOMEFACILITY NUMBER:
198602399
ADMINISTRATOR:TAWFIK, MAGDYFACILITY TYPE:
735
ADDRESS:11528 SAMOLINE STREETTELEPHONE:
(562) 923-7661
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 6CENSUS: 5DATE:
02/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Fionola Cabero, DSPTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was allowed entry into this home by Fionola Cabero Direct Support Professional/DSP and discussed the purpose of today's visit. The facility cares for Developmentally Disabled Adults, age range from 18 through 59, (6) ambulatory only. The facility is serviced by South Central Los Angeles Regional Center. The current census is (5), LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, and observed food supply. This single-story home contains three (3) clients bedrooms, one (1) staff bedroom, two (2) bathrooms, a living room, kitchen, dining area, backyard, and detached garage. Administrator Gamal Tawfik arrived at 11:00am and assisted LPA Pena with the inspection.

LPA along with the Administrator toured the facility with the staff and observed/inspected the following:
  • The facility had a universal entrance screening area including a sign-in sheet, thermometer, and hand sanitizer.
  • Staff screened and took the temperature of LPA upon arrival.
  • COVID-19 signage was placed in several areas including entrance and common areas.
  • LPA observed (1) staff wearing a mask. LPA prompted the other staff member to wear a face covering/mask.
  • Facility has 30 days supply of face masks, hand sanitizers and gowns, but not disposable gloves. PPE supplies is insufficient.
  • There are 3 bedrooms designated for clients and 1 for live-in staff. Client rooms are equipped with the required furnishings.
  • KITCHEN: Knives and medications are locked in the cabinet.
  • Cleaning solutions are stored and locked under the kitchen sink.
  • Sufficient food supply of 2-day perishable but not 7-day nonperishable were observed.
  • LAUNDRY ROOM: it is clean, located in the detached garage, and has cleaning supplies inaccessible to residents
  • The fire extinguisher was last inspected on 3/15/2022. LPA Pena reminded the Administrator Gamal Tawfik to have it inspected prior to the last inspection date.
  • Hot water temperature was measured in the kitchen and the bathrooms and were within the required range of 105-120 degree Fahrenheit.
  • The backyard has a shaded area with tables and chairs for clients use.
  • There are no obstructions to the passageways or bodies of water at the facility.
  • Medications were reviewed for all (5) clients and did not observe any discrepancies.
  • Staff and clients files were not reviewed during today's visit.

Deficiencies were cited, exit interview conducted, and copy of the report and appeals rights were provided to the Administrator, Gamal F. Tawfik.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2023 01:28 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/18/2023 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAMOLINE GUEST HOME
FACILITY NUMBER: 198602399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA observed that the window screen mesh in the clients bathroom was broken which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/28/2023
Plan of Correction
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Administrator will submit photos of the new or repaired window screen and receipts/service order to CCLD on o rbefore the POC due date.
Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview the Administartor did not comply with the section cited above in which the dishwasher in the kitchen was broken and observed to have a trash can stored inside which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/28/2023
Plan of Correction
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Administrator stated that they will remove the dishwasher and put up a board to cover the area. The Administrator will submit photos to CCLD/LPA to prove that the dishwasher has been cleared on or before the POC due date,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/18/2023 01:28 PM - It Cannot Be Edited


Created By: Bennette Pena On 02/18/2023 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAMOLINE GUEST HOME
FACILITY NUMBER: 198602399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in which the facility did not maintain a 7-day supply of non pershables food supplies which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/24/2023
Plan of Correction
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Administartor will purchase additional non persihables food supply and send photos and food purchase receipts to CCLD/LPA on or before the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2023


LIC809 (FAS) - (06/04)
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