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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800454
Report Date: 08/11/2023
Date Signed: 08/11/2023 04:20:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230809115410
FACILITY NAME:FAITHWORKS RESIDENTIAL HOMESFACILITY NUMBER:
331800454
ADMINISTRATOR:GROVE, ZENOBIAFACILITY TYPE:
735
ADDRESS:31922 BAY LAUREL STREETTELEPHONE:
(951) 430-1429
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:4CENSUS: 4DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Staff, Fatmah AbdullahTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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9
Staff failed to seek medical attention for resident
Staff mismanaged residents' medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with staff, Fatmah Abdullah, and spoke with Administrator Zenobia over the phone. Both were informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations, and conducted records reviews.

It was alleged that staff failed to seek timely medical attention for Resident #1 (R1). LPA reviewed the facility's incident reports for R1 and found that incident occuring on 7/17/2023 was reported to R1's medical doctor. LPA interviewed (3) staff members whos stated R1's doctor was informed of R1 consuming another resident's medication and was monitored by staff. Therefore, the allegation that staff did not seek medical attention for R1 is unsubstantited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230809115410

FACILITY NAME:FAITHWORKS RESIDENTIAL HOMESFACILITY NUMBER:
331800454
ADMINISTRATOR:GROVE, ZENOBIAFACILITY TYPE:
735
ADDRESS:31922 BAY LAUREL STREETTELEPHONE:
(951) 430-1429
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:4CENSUS: 4DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Staff, Fatmah AbdullahTIME COMPLETED:
04:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to lack of supervision resident consumed another resident's medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with staff, Fatmah Abdullah, and spoke with Administrator Zenobia over the phone. Both were informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations, and conducted records reviews.

It was alleged that R1 had taken Resident #2 (R2) medication when staff was not supervising medication left on a counter. LPA interviewed (3) staff who stated Staff #1 had left R2's medication and asked Staff #2 (S2) to watch the medication while they stepped out. When S2 had turned around, R1 had taken the medication left on the counter. LPA conducted records review and found that a incident report was filed out by the facility, however there was no record of the report being sent to the regional office. Staff interview revealed that staff training was conducted after the incident for staff. Therefore, the allegation is substantited.

Findings that are suntantited mean that the proponderance of the evidence standard has been met. Deficiencies were cited under California Code of Regulations Title 22. Plan of Correction was discussed with administrtor over the phone. An exit interview was conducted where this report along with 811, deficency page and appeal rights were reviewed with Staff, Fatmah Abdullah.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20230809115410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FAITHWORKS RESIDENTIAL HOMES
FACILITY NUMBER: 331800454
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/18/2023
Section Cited
CCR
80078(a)
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(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirment was not met as evidenced by:
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The licensee agreed to send the LPA proof of training the staff after the incident occured on medication administration. This is due by the POC due date.
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Based on interviews, it was found R1 took R2's medication when staff had turned around. This poses a potential health saftey or personal rights risk
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20230809115410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FAITHWORKS RESIDENTIAL HOMES
FACILITY NUMBER: 331800454
VISIT DATE: 08/11/2023
NARRATIVE
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It was also alleged that staff mismanaged the resident's medications as medication was missing for residents. LPA conducted a random audit of (1) resident's medications and found all medication was accounted for. LPA also reviewed the medication accountability log and found no missing medication for the facility resident. LPA conducted (3) staff interviews and all (3) staff stated medication had not gone missing for the residents. Therefore the allegation is unsubstantiated.

Findings that are unsubstantiated, mean that although the allegations may be valid the preponderance of the evidence standard has not been met. An exit interview was conducted where this report was reviewed and provided to staff, Fatmah Abdullah.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4