198602399-1-15-2026-28-AS-THEA-DQCRZ6-20260115122725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602399
Report Date: 01/15/2026
Date Signed: 01/15/2026 12:27:32 PM

Document Has Been Signed on 01/15/2026 12:27 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 HOME		FACILITY NUMBER:	198602399
ADMINISTRATOR/ DIRECTOR:	TAWFIK, MAGDY		FACILITY TYPE:	735
ADDRESS:	11528 SAMOLINE STREET		TELEPHONE:	(562) 923-7661
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 6		CENSUS: 4	DATE:	01/15/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:52 AM
MET WITH:	Magdy Tawfik - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent case management visit in response to an initial case management dated 10/16/25 following the death of Client #1 (C1), who passed away 10/10/25. LPA met with Administrator Magdy Tawfik and explained the purpose for todays visit. On 10/13/25 the Department received a Death Report indicating the following: On 10/10/25 C1 was observed to grab items from the kitchen that appeared to be food, placed it in their mouth and began to run away. S1 followed them and saw C1 fall in front of their bedroom. S1 tried to remove as much food out of C1’s mouth as possible, struck C1 on the shoulder blades and administered abdominal thrusts. S2 called 911 and the fire department arrived in attempt to save C1’s life but there was no success and C1 was declared deceased at 10:40pm. On 10/15/25 LPA Herrera received copies via email, of the following documents from C1’s file: Death Report, Medical Progress Note dated 9/8/25, Psychiatry Progress Note dated 9/12/25, South Central Regional Center Individual Program Plan dated 2/24/23, ID and Emergency Information, Medication Administration Record (MAR) for Sept-Oct 2025, Annual Behavioral Report dated 8/18/25 and a copy of the Death Certificate “working copy” dated 10/15/2025. C1's most current Appraisal/Needs and Services Plan, and Hospice Notification. On 10/16/25 LPA conducted an initial case management visit and toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed. LPA requested facility to obtain and provide Licensing with C1's Death Certificate (finalized, signed by physician and without the words working copy) upon receipt. On 12/10/25 LPA received a copy of C1’s finalized Death Certificate with the cause of death listed as: Cardio Respiratory Failure, Acute Arrhythmia, Acute Myocardial Infraction, Coronary Artery Disease. Based on statements and interviews conducted with staff and review of C1's files and death report the cause of death does not appear to be suspicious or due to any neglect, therefore the findings 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: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 2