331880633-11-20-2024-18-AS-SSAS-DCH2YJ-20241231164850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880633
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:33:37 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
08/23/2023 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230823135335

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:	08:00 AM
MET WITH:	Ahmad Abdallatef		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff is not providing food to the residents

INVESTIGATION FINDINGS:

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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: 4 out of 4 residents, and 2 of 2 staff.

It is alleged that facility staff is not providing food to the residents. Tour of the physical plant conducted on September 01, 2023, by LPA Arreola and tour conducted on today’s visit by LPA Martinez observations reveled that facility has two refrigerators and 1 freezer as well as 2 pantries and additional food storage in the garage. Interview with 4 of 4 residents revealed that they have never had an issue with the food
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)

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Control Number 18-AS-20230823135335

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

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service at the facility. Residents indicated that facility offers the ability to request food when they are hungry outside of the meals times and that if they request food that they can get it. Snacks are provided, but residents indicated that they like to purchase their own snack and keep a stock of their own snack because it is their right to have what they want at the facility. Residents also indicated that a while back can’t remember when there was a different cook, but facility hired a new person to cook for them and that staff makes way better food for the residents, and they like it much better than before. Interview with staff revealed that residents get their 3 meals every day and snacks in between meals. Residents can request food at any time, and we give accommodate to them as needed, as well as if they don’t like any of the meals being served, they can request an alternative meal and we will prepare for them. Snacks and fruit are available for residents for them to help themselves as well. Records reviewed for weight logs that were received on the visit of September 01, 2023, and today’s visit reveled that 8 out of the 12 residents had a fluctuation in weight gaining and loosing between 1-10 pounds in the span of a year. No resident records reflected a significant weight gain or weight loss in a short period of time or over a year span.

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)

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