331880633-11-20-2024-18-AS-SSAS-DCFQSY-20241230112616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880633
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:34:33 PM

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
07/21/2022 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220721164247

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:	11/20/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ahmad Abdallatef		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not assisting resident to refill their medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to further investigate into the above identified complaint allegation. LPA arrived at facility and was greeted at the door by Fermin Cornista, caregiver and granted entry. Ahmad (Adam) Abdallatef, Administrator arrived shortly after and met with LPA and LPA explained the purpose of the visit.

Findings are based upon this investigation which included records review, interviews with the following: 5 out of 5 residents, and 2 of 2 staff.

It is alleged that staff are not assisting resident to refill their medication. Interview with 2 of 2 staff revealed that resident’s medication is ordered and dispensed through Innovage and they send refills 3-4 days prior to end of month for all residents. Medication comes in a box and is individually packaged for each resident for each dose and time. It makes it easier for staff to dispense medication to each resident. Records
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

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 2

Control Number 18-AS-20220721164247

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: 11/20/2024

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

review for residents MAR sheet for November 2024 observations do not reflect any missed doses for any resident. Interview with 5 of 5 residents revealed that they have always gotten their medication on time and never have missed any doses of the medication in the past. Resident indicated that their medication goes through Innovage and gets sent and filled through that company. They also indicated that they have never had any issues with their medication. LPA Martinez on today’s visit inspected the medication and observed residents’ medication individually boxed and packaged for each dose/time.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2