198602399-7-8-2025-28-AS-DSIS-DJVRZD-20250724132745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602399
Report Date: 07/08/2025
Date Signed: 07/08/2025 12:46:28 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
06/25/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250625083745

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: 5	DATE:	07/08/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Regina Buron - Caregiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility failed to report incidents between clients.
Facility staff did not prevent altercations between clients.
Client sustained unexplained bruising while in care due to lack of care and supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings on the above allegations. LPA met with Regina Buron and explained the purpose of today's visit, LPA also spoke with Assistant Administrator Gamal via phone and delivered finding verbally.

The investigation consisted of the following:

During initial visit dated 7/1/25 LPA attempted interview with Client #1 (C1) (due to cognitive impairment no interview), interview with C2 was conducted and interviews with 3 Staff (S1-S3) were conducted. LPA received the following documents from C1 and C2’s files via email: IPP, Quarterly Behavioral Reports, Client Notes, and Special Incident Reports. 7/8/25 LPA conducted phone interviews with C1 & C2 Responsible Parties. During today’s subsequent visit LPA delivered findings for the above allegations.
(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

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-20250625083745

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: 07/08/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Facility failed to report incidents between clients.
It is alleged that facility staff did not report injuries on C1 to their responsible party. LPA reviewed C1’s file and it was observed that C1 is not conserved and responsible party listed is Regional Center. LPA spoke to C1's service coordinator and it was explained that the incident was reported to Regional Center within the required time fame. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation, S2 and S3 stated that the incident was reported to C1 and C2’s family within 24 hours and within 48 hours the incident was reported to Licensing and Regional Center. LPA reviewed Licensing database to confirm date incident was reported to Licensing, incident was dated 10/15/24, licensing received report by 10/16/24, which cooperates with S2 & S3’s statements.

Allegation: Facility staff did not prevent altercations between clients.

It is alleged that during visits at the facility it was observed that C2 was slapping and bullying other clients. LPA reviewed IPP reports for both C1 and C2 and both clients have behaviors that include physical aggression, self injurious behavior and inappropriate social behavior (touching). LPA spoke to responsible parties for both C1 and C2 and it was stated that although both clients exhibit aggressive behaviors and self-injurious behaviors, the facility has shown that they intervene and do what is needed to prevent altercations. LPA interviewed 3 staff and each denied the above allegation, staff stated that although C2 does exhibit bullying behaviors, staff do intervene by separating clients, calming both parties down, continue to observe and monitor clients when they are in close proximity and have behaviorists that work with the clients. LPA reviewed incident reports and there is documentation of incidents where C2 has aggressive behaviors, intervention was done, and responsible parties were notified.

Allegation: Client sustained unexplained bruising while in care due to lack of care and supervision.

It is alleged that in October of 2024 it was reported that C1 had a bruised eye, and within the same month after a visit with C1 additional bruising was observed on C1’s stomach and scratches on C1’s arms. LPA reviewed Incident Reports and this incident was reported to licensing on 10/16/24, according to report intervention was made and C1 was treated with an ice pack. LPA spoke to responsible parties and both stated that staff have a ratio where both clients are closely monitored at all times, however, incidents make occur due to their disability and behaviors.... (Continued on LIC9099-C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250625083745

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: 07/08/2025

NARRATIVE

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Continuation of Allegation: Client sustained unexplained bruising while in care due to lack of care and supervision.
LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated that staff present at the time did not have a chance to react or prevent incident from occurring as it happened very quickly. C2 had gone to the restroom and C1 was sitting right outside the restroom, as soon as C2 exited the restroom is when the altercation between both clients happened, staff rushed to separate clients, calmed both clients down, provided an ice pack to C1, and monitored both clients. LPA reviewed C1 and C2’s files and its noted within their IPP and Quarterly Behavioral Reports that both clients have aggressive behaviors, however, per staff all clients are monitored and supervised especially when behaviors are present/known. LPA attempted to interview C1 but due to cognitive impairment, interview was not successful, during attempted interview LPA did not observe any bruising, redness or scratches on C1’s face nor arms.

Based on statements and interviews conducted with staff/clients, and review of client files, there was not enough supportive evidence to concur with the reported allegations. 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 this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025

LIC9099 (FAS) - (06/04)

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