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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530063
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:57:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
10/01/2024 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241001153001
FACILITY NAME:SIERRA PINES GUEST HOMEFACILITY NUMBER:
335530063
ADMINISTRATOR:HAMED, HANANFACILITY TYPE:
740
ADDRESS:5051 LA SIERRA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:25CENSUS: 24DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Facility administrator Hanan HamedTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff inappropriately moved resident to another facility.
Staff did not notify resident's authorized representative of the move.
Staff inappropriately had resident sign doucments without authorized representative.
Staff are not providing resident's authorized representative with signed documents and records.
INVESTIGATION FINDINGS:
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First Complaint: Licensing Program Analyst (LPAs) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Facility administrator Hanan Hamed and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation: Staff inappropriately moved resident to another facility.

Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation.

During interviews with facility administrator and records,she reported that R#1 was given notice of moving to another facility and R#1 family was contacted on the phone and have been informed of this move. Documents have been collected from the administrator Hana Hamed.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 3
Control Number 56-AS-20241001153001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SIERRA PINES GUEST HOME
FACILITY NUMBER: 335530063
VISIT DATE: 12/06/2024
NARRATIVE
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Second Allegation: Staff did not notify resident's authorized representative of the move.

Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation.

During Interviews with Facility Administrator Hanan Hamed, she reported that R#1 daughter has been informed of facility moving R#1 to another facility. Records and documentation of phone communication has been provided with the report.

Third Allegation: Staff inappropriately had resident sign documents without authorized representative.

Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation.

During interviews with staffs at the facility, all staff who were interviewed denied R#1 was being moved to other facility without the notice. According to the records R#1 is being capable of signing any documents on his own and can make decisions, all staff interviewed verified there was no evidence of a violation.


Fourth Allegation: Staff are not providing resident's authorized representative with signed documents and records.

Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation.

During Interviews with Facility administrator and staff R#1 has not requested any documents or records from the facility as there are no Life insurance documents has been signed by R#1 while he was at the facility.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241001153001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SIERRA PINES GUEST HOME
FACILITY NUMBER: 335530063
VISIT DATE: 12/06/2024
NARRATIVE
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Based on the evidence found during the investigation, LPA Beena Singh found the allegation listed above to be Unsubstantiated.

Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Facility administrator Hanan Hamed.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3