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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880906
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:12:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/24/2023 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230124092533
FACILITY NAME:A & J RESIDENTIAL CARE FACILITYFACILITY NUMBER:
331880906
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
735
ADDRESS:1229 KELLEY AVETELEPHONE:
(650) 656-7941
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:6CENSUS: 7DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Ahmed Qasim- Facility ManagerTIME COMPLETED:
01:22 PM
ALLEGATION(S):
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Facility staff abused resident financially.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegation. LPA met with Facility Manager Ahmed Qasim and explained the reason for the visit.

During today’s visit, LPA toured the facility, and conducted interviews with clients and staff.

For allegation, Facility staff abused resident financially:

During interviews conducted, LPA discovered that S1 accepted and borrowed money from C1 and C2. Qasim stated that S1 admitted that in 2021 S1 borrowed $200 dollars from C1 and $800 dollars from C2. During interviews with clients, LPA was informed that S1 borrowed $10,000 dollars from C1 and $800 dollars from C2. LPA was informed by Qasim that the police were called, but a police report was not taken.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 3
Control Number 56-AS-20230124092533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A & J RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880906
VISIT DATE: 01/26/2023
NARRATIVE
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Based on the evidence gathered during today’s investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

During today’s visit, one (1) type A deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Facility Manager Ahmed Qasim, along with a copy of LIC9099D, and a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230124092533
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: A & J RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 331880906
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
80072(a)(1)
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80072. Personal Rights. (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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The licensee has agreed to read regulation 80072 entirely and send LPA self-certified letter that the regulation was read and understood. The licensee has agreed to provide a personal rights training to staff. The licensee has agreed to send LPA signed documentation that the staff has attended a training on client personal rights.
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Based on interview, the licensee did not comply with the section cited above evidenced by staff taking advantage of the clients by accepting/taking money from them which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed to contact the police, obtain a police report, and send LPA the police report number. POC is due by 1/27/2023.
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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: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3