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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881282
Report Date: 06/25/2025
Date Signed: 06/25/2025 02:01:10 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
06/19/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250619105858
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:
06/25/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashlee GonzalezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff does not ensure that resident is adequately fed
Staff isolates resident to her bedroom
Staff prohibits resident from accessing the common areas for personal use
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unnannounced visit for the purpose to deliver findings on the allegations listed above. LPA met with House Manager Ashlee Gonzalez and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour.

For the allegation, Staff does not ensure that resident is adequately fed

LPA Hernandez conducted (2) resident interviews. 2 out of the 2 residents stated staff ensure they are adequately fed. Resident #1 (R1) stated Staff #1 (S1) ensures they are fed three times a day and portions are adequate. LPA Hernandez conducted (2) staff interviews. 2 out of the 2 staff stated residents are adequately fed. Additionally, LPA observed non-perishable and perishable food supply sufficient for number of residents in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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-20250619105858
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: AL HAYBA HOME
FACILITY NUMBER: 361881282
VISIT DATE: 06/25/2025
NARRATIVE
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For the allegation, Staff isolates resident to her bedroom

LPA Hernandez conducted (2) resident interviews. 2 out of the 2 residents stated they are not isolated in their bedrooms and are able to go into the living room and outside whenever they may want. LPA Hernandez conducted (2) staff interviews. 2 out of the 2 staff stated residents are not isolated to their bedrooms and are able to come out of their rooms whenever they may like.

For the allegation, Staff prohibits resident from accessing the common areas for personal use

LPA Hernandez conducted (2) resident interviews. 2 out of the 2 residents stated they are able to access common areas for personal use. LPA Hernandez conducted (2) staff interviews. 2 out of the 2 staff stated residents are able to access common areas such as the living room and outside.

Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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 (LIC9099) was discussed and provided to House Manager Ashlee Gonzalez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2