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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880633
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:57:54 PM

Unfounded


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
08/23/2023 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230823135335

FACILITY NAME:CALIFORNIA MANOR GUEST HOME #1FACILITY NUMBER:
331880633
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:8536 & 8548 CALIFORNIA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:12CENSUS: 12DATE:
09/01/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff, Ahamed AbdallatefTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff assaulted residents
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 initate an investigation into the allegations above. LPA met with Staff, Ahamed Abdallatef who was informed of the purpose of the visit.

LPA collected documentation, conducted interviews and documented observations. It was alleged that R1 was assaulted by a staff at the facility. Upon review of the staff roster and staff and resident interviews, it was found that the alleged staff mentioned in the complaint was a resident and not a staff member. Therefore the allegation is found to be unfounded, meaning the allegation is false, could not have happened or is without a reasonable basis.

An exit interview was conducted where this report was reviewed and provided to, Staff, Ahamed Abdallatef.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
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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