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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881116
Report Date: 03/03/2023
Date Signed: 03/03/2023 11:10:27 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230201083616
FACILITY NAME:ELIAA, LLCFACILITY NUMBER:
331881116
ADMINISTRATOR:YOUNES, AMIRRAFACILITY TYPE:
740
ADDRESS:11545 DOVERWOOD DR.,TELEPHONE:
(650) 656-7941
CITY:RIVERSIDESTATE: CAZIP CODE:
92505
CAPACITY:6CENSUS: 6DATE:
03/03/2023
ANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee/Administrator Ahmed QasimTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that residents have access to common areas.
Staff do not ensure that facility is kept clean.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/03/2023 at 11:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Ahmed Qasim at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation and interviews with relevant parties. The allegation indicates that Staff do not ensure that residents have access to common areas. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that residents have access to common areas like the living room, kitchen, backyard and front yard. In addition, staff interviews revealed that no incidents happened
*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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 56-AS-20230201083616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: ELIAA, LLC
FACILITY NUMBER: 331881116
VISIT DATE: 03/03/2023
NARRATIVE
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at the facility where staff restricted residents access to common areas of the facility. During the visit last 02/09/2023, LPA Brown observed residents at the facility at the common area and were not restricted access to the common area of the facility by staffs.

The second allegation indicates that staff do not ensure that the facility’s kept clean. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that the staffs are cleaning the facility every day and facility’s always kept clean. Staffs interviews revealed that they are cleaning the facility every day to make sure that the facility’s always clean and sanitary. During the visit last 02/09/2023, LPA Brown observed the facility’s kept clean. In addition, LPA Brown observed Staff 6 (S6) cleaning the facility and S6 reported to LPA Brown that they are cleaning the facility every day to maintain cleanliness at the facility.

Based on the evidence, the allegation that Staff do not ensure that residents have access to common areas (Allegation #1) and staff do not ensure that the facility’s kept clean (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Licensee/Administrator Ahmed Qasim.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2