374604078-9-30-2022-08-AS-SJAB-CJRV6U-20220930161007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604078
Report Date: 09/30/2022
Date Signed: 09/30/2022 10:18:54 AM

Unsubstantiated

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
04/28/2020 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20200428172657

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: 6	DATE:	09/30/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Majida "Maggie" Houaoura		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek medical attention for resident as requested

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Majida "Maggie" Houaoura.

The Department’s investigation consisted of interviews, review of records, and a tour of the facility. It was alleged that the staff did not seek medical attention for a resident as requested. Interviews and review of Client 1’s (C1) medical records revealed that C1 has a history of physical aggression, yelling, cursing, slamming doors, and throwing and breaking items. San Diego Regional Center has advised staff to ask C1 to talk through C1’s frustrations and redirect C1 to participate in other activities. Review of C1’s medical documents revealed that C1 is able to communicate their needs. Interviews and record review revealed that around 12:30pm on 4/22/2020, C1 began becoming agitated. Staff attempted to redirect and deescalate C1 by asking C1 if C1 wanted to go on a walk, water plants, or watch television.
Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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 08-AS-20200428172657

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: 09/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews with the Licensee revealed that around 3pm, C1 became more agitated and began throwing things, made threats of self-harm, and made verbal threats against staff and clients. While C1 was agitated, C1 injured Staff 1’s (S1’s) finger. The facility staff called the La Mesa Police Department and Psychiatric Emergency Response Team (PERT). Interviews with the Licensee revealed that it did not take long for PERT to arrive and PERT took C1 to the hospital. C1 was not admitted and was discharged on the following day on 4/23/2020.

The Department has investigated the above-mentioned allegation and based on observation, record review, interviews, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Caregiver Majida "Maggie" Houaoura, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2