331880633-9-12-2025-18-AS-JDHS-DLLN2P-20250917100503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880633
Report Date: 09/12/2025
Date Signed: 09/12/2025 09:26:12 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
07/29/2025 and conducted by Evaluator Armando Perez

COMPLAINT CONTROL NUMBER: 18-AS-20250729094957

FACILITY NAME:	CALIFORNIA MANOR GUEST HOME #1		FACILITY NUMBER:	331880633
ADMINISTRATOR:	HAMED, NAJEH		FACILITY TYPE:	740
ADDRESS:	8536 & 8548 CALIFORNIA AVE		TELEPHONE:	(786) 219-6008
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	12	CENSUS: 12	DATE:	09/12/2025
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	House Manager Fermin Cornista		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

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Facility staff did not provide resident roster to Ombudsman.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with House Manager Fermin Cornista, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, observations, and file reviews.

On July 29, 2025, Community Care Licensing received a complaint alleging facility staff did not provide a Resident Roster (LIC 9120) to the Long-Term Care Ombudsman (LTCO). Throughout the investigation, LPA interviewed staff and residents and obtained supportive documentation to aid in determining the findings of the noted allegations.

Interview with Witness 2 (W2) reported that on June 26, 2025, a copy of the LIC9120 was requested from Administrator Najeh Hamed. W2 reported Hamed indicated they would email the form.
Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

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 18-AS-20250729094957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1	FACILITY NUMBER: 331880633
	VISIT DATE: 09/12/2025

NARRATIVE

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W2 reported that due to email issues, it is unknown whether the roster was sent by Hamed and not received due to technical issues or if Hamed simply never emailed the form. W2 reported a document was provided that appeared either incomplete or outdated. It could not be confirmed if this was the current LIC9120. A copy of this document was not obtained.

Interview with Administrator Hamed revealed that on June 26, 2025, Hamed recalls being asked for the LIC9120. The Administrator revealed they recalled a discussion where it was mentioned that some information was missing from the LIC9120 and it was requested that the information be added to the form. Administrator Hamed reported that a request to email the LIC9120 was not received as it was Hamed’s observation that the form was received.

Interview with 3 of 3 staff revealed they are aware of providing requested documentation upon request. Staff reported a current resident roster is posted in the designated staff area for review.

Based on record review, staff and witness interviews, the allegation that facility staff did not provide resident roster to Ombudsman is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where a copy of this report was provided to facility representative.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

LIC9099 (FAS) - (06/04)

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