374604078-10-5-2021-08-AS-JRAE-C89U53-20211029151600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604078
Report Date: 06/23/2021
Date Signed: 10/05/2021 01:53:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2020 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20200821103147

FACILITY NAME:	MARYAM RCFE		FACILITY NUMBER:	374604078
ADMINISTRATOR:	DOST, LEEDA		FACILITY TYPE:	740
ADDRESS:	4930 MAIDEN LANE		TELEPHONE:	(858) 348-7247
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 5	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	12:03 PM
MET WITH:	Sahym Meza, Caregiver		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff member abuses residents and staff
Staff member neglects residents' basic care needs
Staff member fails to treat residents with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)Tiffany Holmes arrived at the facility to deliver findings for a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Sahym Meza, Caregiver. LPA previously conducted interviews, made observations, and obtained and reviewed pertinent records. LPA conducted the initial visit on August 26, 2020, and conducted a tour of the facility. It was alleged staff member abuses residents and staff. Interviews did not reveal any physical or emotional abuse by staff. Staff 1 (S1) (see LIC811 Confidential Names List) in question denies abusing any residents or staff. S1 does not speak rudely or mean to the other staff or residents. S1 admits to doing the best they can on their job. There were no witnesses to prove staff member abuses residents and staff.
Continued...

* This is an amended report from 06/23/2021

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200821103147

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MARYAM RCFE	FACILITY NUMBER: 374604078
	VISIT DATE: 06/23/2021

NARRATIVE

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It was alleged staff member neglects residents' basic care needs. Interviews revealed that residents needs are met and anytime they need assistance they receive it. Interviews revealed staff check on residents frequently. Staff provides meals and assistance to the residents several times on a daily basis. The residents receive assistance with bathing and dressing. There were no witnesses to prove staff neglects residents basic care needs.

It was alleged staff member fails to treat residents with dignity and respect. Interviews revealed that staff talk and treat the residents kindly. Interviews revealed staff respect the residents needs and their wants. Interviews revealed there haven't been any instances when staff have been rude or disrespectful at any time. There were no witnesses to prove staff member fails to treat residents with dignity and respect.

Based on interviews conducted, the allegations are unsubstantiated. This agency has investigated the complaint alleging staff member abuses residents and staff, staff member neglects residents' basic care needs and staff member fails to treat residents with dignity and respect We have found the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred.

An exit interview was conducted with Licensee, Sahym Meza, Caregiver and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Licensee, Leeda Dost via email. An electronic email read receipt confirms the documents were received.

** This is an amended report from 06/23/2021**

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

LIC9099 (FAS) - (06/04)

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