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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880863
Report Date: 06/08/2023
Date Signed: 06/08/2023 01:52:29 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
05/19/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230519161759
FACILITY NAME:ALOHA RESIDENTIAL CAREFACILITY NUMBER:
361880863
ADMINISTRATOR:KHAN, ASMATFACILITY TYPE:
740
ADDRESS:7476 BUNGALOW WAYTELEPHONE:
(951) 675-7763
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY:6CENSUS: 6DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Asmat Khan TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff is unable to communicate with residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Asmat Khan and explained the purpose of the visit. The investigation consisted of staff and resident’s interviews.

First allegation: Staff is unable to communicate with residents.

Upon entry into the facility, LPA asked Staff #1 how many staff were working in the facility. Staff #1 did not respond to LPA. LPA asked Staff #1 if staff understood English Staff #1 responded “NO” LPA asked Staff #1 if Staff #2 understood or spoke English Staff #1 responded “NO” Staff #1 brought their cellphone and LPA observed Staff #1 typing in a translator application stating that Facility Administrator should be on their way. During interviews conducted today, LPA found that all six (6) residents in care don’t speak or understand Spanish. In addition, residents have a hard time communicating with staff due to language barriers.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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 5
Control Number 56-AS-20230519161759
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: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
VISIT DATE: 06/08/2023
NARRATIVE
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Based on the evidence gathered, LPA found that Staff #1 and Staff #2 at the facility are not able to adequately communicate to ensure the safety of the residents in care.

Based on the evidence gathered during today’s investigation, the allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence the standard has been met.

During today’s visit, one (1) 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 Administrator Asmat Khan, along with a copy of LIC9099D, and a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 56-AS-20230519161759
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: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87411(a)
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87411. Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidence by:
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Licensee has agreed to read regulation 87411 entirely and send LPA a signed and written statement via email indicating that Licensee has read and understands regulation and will ensure complience by scheduling staff effectively communicating with residents in care, emergency personnel, licensing, and others. POC is due by 7/14/23
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Based on observation, interviews and record review, the lincensee did not ensure personnel requirements were obtained, 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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/19/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230519161759

FACILITY NAME:ALOHA RESIDENTIAL CAREFACILITY NUMBER:
361880863
ADMINISTRATOR:KHAN, ASMATFACILITY TYPE:
740
ADDRESS:7476 BUNGALOW WAYTELEPHONE:
(951) 675-7763
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91739
CAPACITY:6CENSUS: 6DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Asmat Khan TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
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9
Medication is being transferred to another container
Facility has no planned activities
INVESTIGATION FINDINGS:
1
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5
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Asmat Khan and explained the purpose of the visit. The investigation consisted of staff and resident’s interviews.

First allegation: Medication is being transferred to another container.

Regarding the first allegation, Medication is being transferred to another container. LPA conducted an inspection where medication was audited at random, and medications appeared to be dispensed appropriately by staff members. LPA observed medication to be locked and inaccessible to clients. LPA observed that noon medication was being dispensed during the visit. LPA also observed that the correct medication was being dispensed according to the residents scheduled time.

Second allegation: Facility has no planned activities.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20230519161759
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: ALOHA RESIDENTIAL CARE
FACILITY NUMBER: 361880863
VISIT DATE: 06/08/2023
NARRATIVE
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Regarding the second allegation, Facility has no planned activities. LPA conducted a facility inspection and LPA observed a good number of activities available for residents. During the inspection LPA also observed an activity calendar posted for the month June, with all the planned activities listed for the month of June. Due to a lack of information, the above allegations are deemed UNSUBSTANTIATED at this time.


Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and provided to Facility Administrator Asmat Khan
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5