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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530060
Report Date: 06/19/2024
Date Signed: 06/19/2024 12:19:47 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
02/27/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240227125805
FACILITY NAME:SELENA SENIOR HOME LLCFACILITY NUMBER:
365530060
ADMINISTRATOR:HUSSEIN, SHADENFACILITY TYPE:
740
ADDRESS:9713 EUGENIA AVETELEPHONE:
(205) 777-9144
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 6DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Fadi Suleiman- AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff illegally evicted resident
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 Fadi Suleiman and explained the purpose of the visit. The investigation consisted of interviews and record review.

First allegation, Staff illegally evicted resident. During the course of the investigation, interviews were conducted, a review of resident (R1) records was completed and copy of pertinent documents were obtained. Regarding the alleged violation of staff illegally evicted resident, LPA reviewed Title 22 of The California Code of Regulations section pertaining to eviction procedures. LPA discovered that facility did not provide resident (R1) or the responsible party with a 30-day notice discussing the reason for the eviction in addition, the facility did not seek licensing approval for the eviction.
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: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 4
Control Number 56-AS-20240227125805
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: SELENA SENIOR HOME LLC
FACILITY NUMBER: 365530060
VISIT DATE: 06/19/2024
NARRATIVE
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Based on the evidence gathered during the investigation, the above allegation is Substantiated.

Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Eviction Procedures 87224(a)(2) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Administrator.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20240227125805
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: SELENA SENIOR HOME LLC
FACILITY NUMBER: 365530060
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
CCR
87224(a)(2)
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87224(a)(2) Eviction Procedures... (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).... (2)Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following:

This requirement is not met as evidence by:
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Administrator has agreed to review the entire Eviction Procedures regulation and complete a statement of understanding and provide a signed and dated copy of the understanding to LPA Guerrero by POC date 7/12/2024.
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Bases on review of records the licensee did not ensure to follow the proper eviction procedures for Resident #1 based on Title 22 regulations, 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: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/27/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240227125805

FACILITY NAME:SELENA SENIOR HOME LLCFACILITY NUMBER:
365530060
ADMINISTRATOR:HUSSEIN, SHADENFACILITY TYPE:
740
ADDRESS:9713 EUGENIA AVETELEPHONE:
(205) 777-9144
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 6DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Fadi Suleiman- AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff refused to return resident's personal items.
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 Fadi Suleiman and explained the purpose of the visit. The investigation consisted of interviews and record review.

Second allegation, Staff refused to return resident's personal items. During the course of the investigation, interviews were conducted with relevant parties. During the interviews pertaining to the allegation of staff refused to return resident's personal items, family informed LPA that resident (R1), personal belongings were picked at the facility by resident (R1) family members at a later time. due to a lack of information, this allegation is 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 appeal rights were provided to Facility Administrator Fadi Suleiman.
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: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4