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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881569
Report Date: 05/20/2025
Date Signed: 06/16/2025 10:06:58 AM

Document Has Been Signed on 06/16/2025 10:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GENTLE CARE ESTATES LLCFACILITY NUMBER:
331881569
ADMINISTRATOR/
DIRECTOR:		HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:18183 HAINES STTELEPHONE:
(786) 564-3771
CITY:PERRISSTATE: CAZIP CODE:
92570
CAPACITY: 6CENSUS: 21DATE:
05/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Rebecca CarrascoTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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On 05-20-25, Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Janira Arreola conducted a visit to the facility to conduct a case management . LPAs were greeted and granted entrance by Caregiver Sable Smith. LPAs identified themselves and discussed the purpose of the visit. Licensee Ebraheem Hamed joined the visit at a later time.
LPAs conducted a health and safety check by conducting tour of the facility. The facility is a single story building with five (5) residents bedroom, two (2) staff rooms, two(2) living rooms, an office, a dining room and a detached garage. During the visit, LPAs observed an additional unit on the property, which is a single story building with eight(8) bedrooms, four (4) bathrooms, a living room, a dining room and an outdoor area, with 16 residents residing on the premise. LPA conducted interviews with Licensee Ebraheem Hamed who stated the additional unit is an independent living facility that does not have any relationship with the licensed facility. LPAs advised licensee that since the other unit is at the same address as the licensed facility with 16 residents, the facility is over capacity. A citation will be issued. During the visit, LPAs interviewed residents and staff, and information obtained revealed the Administrator is having a romantic relationship with resident (R1) since last year. The licensee stated they were not aware of any relationship happening between the administrator and the resident. The licensee terminated the Administrator with an immediate effect of 05-20-25 and the Administrator vacated the facility at the time of the visit.
An exit interview was conducted and this report was reviewed, a copy of the 809, 809-D and appeal rights were provided the licensee Ebraheem Hamed
NAME OF LICENSING PROGRAM MANAGER: Rikesha Stamps
NAME OF LICENSING PROGRAM ANALYST: Abdoulaye Zerbo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/16/2025 10:06 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 05/20/2025 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GENTLE CARE ESTATES LLC
FACILITY NUMBER: 331881569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/21/2025
Section Cited
CCR
87204(a)

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87204 Limitations - Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time...This requirement was not met as evidenced by:
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Licensee stated they will relocate the residents within 48 hours and provide proof of correction to LPA by POC due date
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Based on observation, record review and interview, licensee did not comply with the section cited above. A separate unit using the same address was observed at the back of the facility, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/21/2025
Section Cited
HSC1569.58(a)(2)

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1569.58 Persons prohibited from being a licensee, owning beneficial interest in licensed facility, or holding certain positions or employment; grounds; notice; removal; appeal; petition for reinstatement.(a) The department may prohibit any person from being a licensee,…or allowing in a licensed facility,…, any employee, prospective employee, or person who is not a client and who has done any of the following:(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility,....This requirement was not met as evidenced by:
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Licensee terminated the staff member on 05-20-25, and LPAs observed the staff vacate the premises
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Based on interviews , licensee did not comply with the section cited above. An employee was having a romantic relationship with a resident (R1), which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Rikesha Stamps
NAME OF LICENSING PROGRAM MANAGER:
Abdoulaye Zerbo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
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