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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881282
Report Date: 09/16/2025
Date Signed: 09/16/2025 11:06:01 AM

Unsubstantiated


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
09/14/2025 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250914121955
FACILITY NAME:AL HAYBA HOMEFACILITY NUMBER:
361881282
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:13849 COBBLESTONE CTTELEPHONE:
(786) 564-3771
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 3DATE:
09/16/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ashlee Gonzalez- House Manager TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff does not ensure facility has adequate food supply.
Staff does not ensure facility provides quality food.
Staff are not practicing safe food practices.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility House Manager Ashlee Gonzalez and explained the purpose of the visit. The investigation consisted of interviews and observations.

First allegation: Staff does not ensure facility has adequate food supply. Regarding the allegation LPA conducted an inspection of facilities food supply during the inspection LPA observed enough food supply inside refrigerator and freezer to meet the needs of three residents. During the inspection LPA observed food to be fresh, safe, and shelf stable. During the inspection LPA observed facility to have a deep freezer LPA observed a good amount of food supply being stored. LPA conducted interviews with Resident #1 and R#2, regarding the allegation stated above and both residents stated that facility feeds them well and have no concerns regarding food. Resident #1 and Resident #2 informed LPA that facility feeds them three times a day (breakfast, lunch, and dinner), and in between snacks. LPA conducted an interview with Staff #1 LPA went over the allegation with S#1 and Staff #1 informed LPA that the facility
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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 2
Control Number 56-AS-20250914121955
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: AL HAYBA HOME
FACILITY NUMBER: 361881282
VISIT DATE: 09/16/2025
NARRATIVE
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currently grocery shops once a month for three residents and will go up to twice a month when facility is at capacity. In addition, Staff #1 informed LPA that facility will do small restock when needed.

Second allegation: Staff does not ensure facility provides quality food. Regarding the allegation LPA conducted an inspection of facilities food quality during the inspection LPA observed facility to have an adequate amount of quality food to meet the needs of three residents in care. In addition, LPA observed that a food menu for the week was posted. LPA conducted an interview with R#1 and R#2, LPA went over the allegation with both residents and R#1 and R#2 informed LPA that they are not on food restrictions or special food diets, and they like to choose or have options on what they like to eat at the facility. In addition, R#1 and R#2 informed LPA that they like the quality of food that is served and have no concerns regarding the food quality at the facility. LPA conducted an interview with S#1 regarding the allegation stated above S#1 informed LPA that a menu is posted for the week and other options are also made available to residents.

Third allegation: Staff are not practicing safe food practices. Regarding the allegation stated above LPA conducted an inspection along with a walkthrough concerning the allegation stated above during the inspection LPA observed that facilities refrigerator and freezer is following the temperatures of 45 F (7.2 C) and 0 F (-17.7 C) based on Tile22 regulation. During the inspection LPA did not observe frozen food or Tilapia packages to be left out in the kitchen or out in the patio. LPA conducted interviews with R#1 and R#2 regarding the allegation stated above both residents informed LPA that they have no concerns regarding the food. R#1 and R#2 informed LPA that they have no concerns on how the food is prepared and that they have not gotten sick from the food. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

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 (LIC 9099) was discussed, and a copy was provided to Facility House Manager Ashlee Gonzalez at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2