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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880633
Report Date: 07/11/2025
Date Signed: 07/11/2025 12:06:54 PM

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
05/29/2025 and conducted by Evaluator Armando Perez
COMPLAINT CONTROL NUMBER: 18-AS-20250529222455
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:
07/11/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Ahmad AbdallatefTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff did not prevent an altercation between residents resulting in resident's injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Administrator, Ahmad Abdallatef, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews.

On May 29, 2025, Community Care Licensing received a complaint alleging facility staff did not prevent an altercation between residents resulting in resident's injury. Throughout the investigation, LPA interviewed staff and residents and obtained supportive documentation to aid in determining the findings of the noted allegations.Through interview with Administrator Najeh Hamed, it was confirmed that the incident did occur, but staff was present and available to separate the residents and diminish any further acts. Additional interviews with multiple staff members corroborated that the incident on May 26, 2025, involving Residents R1 and R2 did occur.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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 18-AS-20250529222455
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: 07/11/2025
NARRATIVE
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It was the first documented case of aggression between the residents and measures were promptly implemented to prevent a recurrence. Through interview with R1, it was discovered that they initiated the altercation with R2 due to discomfort caused by R2’s smile and loud outburst. R1 shared that the staff quickly intervened to de-escalate the situation and medical attention was provided after R1 reported experiencing pain. Interview with R2 stated that they acknowledged making a statement to R1 that led to the incident. Additionally, R2 described the incident with R1 as an accident and reported that staff quickly responded to de-escalate the situation. Through interview with Additional Witness 1 (AW1), it was revealed that they were made aware of the incident by R1 and subsequently discussed preventive strategies with the Administrator. AW1 stated that they followed up with R1 and no further altercations have occurred with R2. AW1 stated they had no further concerns regarding staff’s intervention or engagement with residents. Additional interviews with residents reported no concerns regarding staff not preventing altercations between residents. A record review confirmed that facility staff had completed training in incident reporting, as well as in de-escalation, and behavioral management techniques.

Based on observation, record review, client, and staff interviews, the allegations that staff did not prevent an altercation between residents resulting in resident's injury is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where a copy of this report was provided to facility representative.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
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