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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602399
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:51:13 PM

Substantiated


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
02/27/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240227110043
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: 6DATE:
03/04/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Magdy Tawfik, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not properly supervising a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Knishi conducted an initial complaint visit to investigate the above allegation. LPAs met with Servillano Sumalbag, Direct Support Professional I & II (DSP I & II) and Eleanor Cardenas, Direct Care Staff and discussed the purpose of today's visit. Shortly after, Gamal Tawfeek, Assistant Administrator and Magdy Tawfeek, Administrator arrived and assisted LPAs with the investigation.

The investigation consisted of the following: LPAs obtained copies of Client & Staff Rosters, Client #1 (C1)-Client #6 (C6) Face sheet/Placement Information and Adult Day Program information. LPAs interviewed Staff #1 (S1) - Staff #4 (S4) and Client #1 (C1) - Client #2 (C2) telephonically. LPAs interviews with Client #3 (C3) - Client #6 (C6) were unsuccessful due to the clients are non verbal. LPAs also conducted a tour of the facility, including the backyard. LPAs also conducted tour of the neighbor's backyard. *****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
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 3
Control Number 28-AS-20240227110043
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: 03/04/2024
NARRATIVE
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The investigation revealed the following:

In regards to the allegation:"Staff are not properly supervising a resident." It is alleged that a resident keeps throwing an orange or a tangerine type of fruit over the neighbor's backyard and and that the fruit is falling into the pool and hot tub which is staining their cement and affecting their pool's filter system. Interviewed staff stated that their neighbors had approached them about the incident 2x, first time it happened was sometime in July/August 2023 and the recent one was last week. S1 stated that he spoke with C1 and reminded him not to throw things to the neighbor's property to keep a good relationship with them. Some staff interviewed indicated that they are aware of the allegation and already spoke to the neighbors to explain and apologize. C1 admitted throwing the fruits in the neighbor's backyard and stated that he was spoken to by staff to stop doing it. LPAs observed that the fruit tree bears a lot of fruits and the branches are hanging over the facility's fence. LPAs also observed fruit marks on the neighbor's backyard cement.

Based on LPAs observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to Magdy Tawfik, Administrator along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240227110043
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision.. (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Licensee/Administrator shall conduct staff training pertaining to Title 22 80078. Administrator also agreed to trim the tree and clear the branches hanging over the neighbor's yard and submit photos and proof of corrections by POC due date.
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Based on observations and interviews, the Licensee/Administrator did not assure that the facility clients are supervised as required per Title 22. Resident had been throwing items in the neighbor’s property and staff are unaware which poses an immediate health and safety risk to clients in care.
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ILS
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3