<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602563
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:55:27 PM

Substantiated


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
08/25/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210825110856
FACILITY NAME:RAHMAAN HOMEFACILITY NUMBER:
198602563
ADMINISTRATOR:RAHMAAN, ALMAFACILITY TYPE:
735
ADDRESS:1345 ASHPORT STTELEPHONE:
(909) 622-0662
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY:4CENSUS: 3DATE:
08/27/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Keith Colder (DSP)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left client unattended.
Medications found on the floor in the client's room.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Keith Colder and explained the purpose of the visit.

During today's visit, LPA obtained/reviewed a copy of the Staff schedule/Client roster and a copy of Client #1's Physician's Report. LPA interviewed Staff #1 in the office at 10:30 am, interviewed Client #1 in the office at 10:50 am, interviewed Staff #2 via telephone at 11:25 am and toured the facility with Staff #1 at 11:45 am.

In regards to the allegation: Staff left client unattended. Interviews with Staff, Client and Witness indicate that on the morning of 08/24/21, Client #1 was left alone in the facility without supervision from approximately 8:00 am to 10:15 am.

Continue to LIC9099C.....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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-20210825110856
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: RAHMAAN HOME
FACILITY NUMBER: 198602563
VISIT DATE: 08/27/2021
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
26
27
28
29
30
31
32
In regards to the allegation: Medications found on the floor in the client's room. Interviews with Staff, Client and Witness indicate that Vitamins were found in Client #1's bedroom. During a tour of Client #1's bedroom, LPA observed an open bottle of Vitamin C.

Based on LPA's observations, record review and interviews, investigation revealed that: the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

An immediately civil penalty of $500 assessed on the LIC421M page.

Exit interview conducted with Keith Colder and copy of the complaint report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210825110856
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: RAHMAAN HOME
FACILITY NUMBER: 198602563
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/28/2021
Section Cited
CCR
80065(a)
1
2
3
4
5
6
7
80065(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by: Interviews with Staff, Client and Witness indicate that on the morning of
1
2
3
4
5
6
7
Licensee shall review Section 80065 and ensure that facility employ personnel necessary to provide services necessary to meet individual client needs at all times. Licensee shall also provided additional training to all staff to not leave clients unsupervised and provide a signed statement that Licensee has reviewed and understood
8
9
10
11
12
13
14
08/24/21, Client #1 was left alone in the facility without supervision from approximately 8:00 am to 10:15 am.
8
9
10
11
12
13
14
Section 80065 and provide proof of staff training to the department by the POC date.

***Note: An immediately civil penalty of $500 assessed on the LIC421M page.***
Request Denied
Type A
08/28/2021
Section Cited
CCR
80075(k)(1)
1
2
3
4
5
6
7
80075(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Interviews with Staff, Client and Witness
1
2
3
4
5
6
7
Licensee shall review Section 80075 and provide a signed statement understanding and ensuring that all medications will be centrally stored and kept safe and locked in a place not accessible to persons other than employees responsible for the supervision of the centrally stored medications by the POC date.
8
9
10
11
12
13
14
indicate that unprescribed Vitamins were found in Client #1's bedroom. During a tour of Client #1's bedroom, LPA observed an open bottle of Vitamin C.
8
9
10
11
12
13
14
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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3