198602399-10-13-2023-28-AS-RORN-CWPTUD-20231017150209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602399
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:04:42 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
08/21/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230821131047

FACILITY NAME:	SAMOLINE GUEST HOME		FACILITY NUMBER:	198602399
ADMINISTRATOR:	TAWFIK, MAGDY		FACILITY TYPE:	735
ADDRESS:	11528 SAMOLINE STREET		TELEPHONE:	(562) 923-7661
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:			TIME COMPLETED:	03:19 PM

ALLEGATION(S):

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Facility staff did not ensure that trash is being properly disposed.
Facility staff are not supervising a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Magdy Tawfik (Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 08/24/2023, LPA obtained a copy of the client and staff rosters. LPA interviewed the Administrator, Staff 1 - Staff 2 (S1 - S2) and Regional Center Representative. LPA obtained a copy of Client 1 (C1) Face Sheet, Individual Program Plan (IPP) and Physician Report. Today's visit, LPA interviewed Administrator, Staff 3 - Staff 4 (S3 - S4), Client 1 - Client 2 (C1 - C2), and attempted to interview Client 3 - Client 6 (C3 - C6) (non-verbal) and Regional Center Representative.

The investigation revealed the following: regarding the allegation "Facility staff did not ensure that trash is being properly disposed”, it is alleged that C1 cleans the front yard and throws the garbage onto the neighbors yard. (Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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Control Number 28-AS-20230821131047

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: SAMOLINE GUEST HOME	FACILITY NUMBER: 198602399
	VISIT DATE: 10/13/2023

NARRATIVE

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Administrator and staff denied the allegation. Staff stated that C1 likes to clean the front yard and one time C1 tried to clean the neighbor's yard, but staff quickly intervene. Staff stated that C1 has never tried to disposed trash in the neighbor's yard. C1 denied disposing trash in the neighbor's yard. C2 could not corroborate the allegation. Regional Center Representative stated that they visited the facility and they observed no issues.

Regarding the allegation "facility staff are not supervising a resident”, it is alleged that C1 is lurking, and looking in at a neighbor's backyard and speaks to the neighbor's kids. Administrator and staff denied the allegation. Staff stated that C1 has never attempted to speak to any kids and C1 is not lurking over the wall. Staff stated that C1 is taller than the wall and when C1 gets near the wall the neighbors could probably see C1, but C1 is not lurking and being invasive. C1 denied the allegation and C2 could not corroborate the allegation. Regional Center Representative stated that they visited the facility and they observed no issues.

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 the report was provided

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

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