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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602399
Report Date: 04/26/2022
Date Signed: 04/26/2022 11:38:28 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/19/2022 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20220419101509
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:
04/26/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tawfik Magdy, administratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Unclear adults providing care
Facility does not have enough food for residents
INVESTIGATION FINDINGS:
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On 4/26/22 at 9:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint investigation to the facility. Upon arrival, LPA met with S1 and explained the purpose of the visit. S1 called administrator Magdy Tawfik, and LPA explained the reason for this visit. Administrator Tawfik joined the visit at 10:30 a.m.

During the visit, LPA checked the food supply and took photos. LPA obtained a copy of resident/ staff roster, receipts of food purchases, and weekly food list made to the administrator. LPA interviewed residents R1 and R2. LPA Interviewed administrator, Staff S1 and S2.

The investigation reveals the following: Regarding "uncleared adults providing care" it is alleged that the facility allows adults without background clearance and association to work in the facility. During the visit, LPA reviewed the staff roster and observed that all staff present is associated with the facility. LPA interviews revealed that 2/2 clients named staff that is cleared and associated to the facility. 3/3 staff named staff that is cleared and associated to the facility.
Reported continued 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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-20220419101509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAMOLINE GUEST HOME
FACILITY NUMBER: 198602399
VISIT DATE: 04/26/2022
NARRATIVE
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The investigation reveals the following: Regarding "Facility does not have enough food for residents", it is alleged that staff must purchase food for residents to eat. LPA observed the food menu and food supply. The administrator confirmed weekly delivery of food supplies and petty cash available for staff use. 2/2 of clients stated they have enough food and receive 3 meals a day with snacks. 1/2 staff state that the facility has enough food and receive a weekly delivery of food supplies.

Based on LPA's interviews, observations, and file review, the investigation revealed: 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 UNSUBSTANTIATED.

Exit interview conducted with administrator Tawfik

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2