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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880633
Report Date: 06/12/2024
Date Signed: 06/13/2024 08:01:48 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
06/03/2024 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240603134430
FACILITY NAME:CALIFORNIA MANOR GUEST HOME #1FACILITY NUMBER:
331880633
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:8536 & 8548 CALIFORNIA AVETELEPHONE:
(786) 219-6008
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:12CENSUS: 10DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Ahmad 'Adam' Abdallatef, Staff/ManagerTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not prevent resident from taking another resident’s belongings
Staff did not prevent resident from injuring another resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Stephanie Martinez and Seo Jeon, conducted an unannounced visit to the facility to start the investigation into the above allegations. The LPAs met with Staff, Ahmad 'Adam' Abdallatef, and informed him of the purpose for the visit.

An allegation was received by the Department alleging that on or around 05/30/2024 Resident Two (R2) went into the bedroom of Resident One (R1) and took a pair of shoes. During the initial visit the LPAs toured the home, conducted staff and client interviews, reviewed records, and obtained copies. R1 was interviewed and confirmed their shoes were stolen by R2. R1 reported they know R2 stole their shoes because R2 told them they had done so. R2 was interviewed and denied taking R1's shoes; rather R2 stated R1 gifted them the shoes, for which they later returned. R2 stated they returned the shoes after R1 began to accuse them of taking the item. Two (2) additional resident interviews were conducted; one resident reported they did not know whether R2 stole R1's shoes and the second resident reported R1 gave R2 the shoes. Staff interviews reported no knowledge of whether R2 stole the shoes. Therefore, due to conflicting information, this allegation is
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 2
Control Number 18-AS-20240603134430
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CALIFORNIA MANOR GUEST HOME #1
FACILITY NUMBER: 331880633
VISIT DATE: 06/12/2024
NARRATIVE
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deemed UNSUBSTANTIATED at this time.

A second allegation was received by the Department alleging that when R1 requested the shoes be returned then R2 became upset and threw the shoes at the resident. It was reported the shoes hit the right side of R1's head causing a bump. R1 was interviewed and confirmed the alleged incident did take place. R2 was interviewed and reported they did throw the shoes at R1; however, the shoes landed on R1's lap. The additional two (2) interviews conducted with residents who witnessed the alleged incident were inconsistent. Although both residents reported R2 threw the shoes; one resident stated the shoes hit the resident in the head while the other stated the shoes landed near the resident's side torso. Staff interviews could provide no information on whether R2 threw the shoes at R1 or not. According to Administrator Najeh Hamed, R1 was assessed for injuries of which none were found. All interviews reported no prior related incidences or history. Resident interviews confirmed staff do supervise residents in care. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
An exit interview was conducted with staff Abdallatef and signatures were received from staff, Formin "Chris" Cornista.


NOTE: Due to difficulties with equipment a handwritten copy was created and left at the facility.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
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