331881116-10-27-2023-56-AS-EMAN-CX4SH9-20231030135310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881116
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:37:59 PM

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
03/08/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230308123000

FACILITY NAME:	ELIAA, LLC		FACILITY NUMBER:	331881116
ADMINISTRATOR:	YOUNES, AMIRRA		FACILITY TYPE:	740
ADDRESS:	11545 DOVERWOOD DR.,		TELEPHONE:	(650) 656-7941
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	6	CENSUS: 6	DATE:	10/27/2023
		ANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Licensee/Administrator Ahmed Qasim		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Adult residing in the facility is using illegal drugs inside of the facility.
Staff did not assist resident with administering medications as prescribed.
Staff did not assist resident with obtaining medical care.
Staff did not provide resident with a copy of an admissions agreement.

INVESTIGATION FINDINGS:

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On 10/27/2023 at 12:00 PM, 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 allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

The Department conducted investigation into allegation of Staff # 6 (S6) used illegal drugs inside the facility. Former Resident #1 (R1) reported allegedly witnessing S6 smoking crack and meth inside the facility. The investigation consisted of interviews with residents and staff members. Residents and staff interviews indicated they did not witness S6 using illegal drugs inside the facility. Therefore, based on the evidence obtained during the Department’s investigation, the allegation of Staff #6 used illegal drugs inside the facility is unsubstantiated at this time.
*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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 3

Control Number 56-AS-20230308123000

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: 10/27/2023

NARRATIVE

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The second allegation alleges that Staff did not assist resident with administering medications as prescribed. LPA Brown did not find evidence to corroborate the allegation. S1 reported to LPA Brown that R1 was never a resident at their facility but resided at the back building with a different Operator. Interviews with Resident #2 (R2), Resident #5 (R5), Resident #7 (R7) and Resident #8 (R8) indicated that they do not know R1 and they all cannot remember who R1 was. R2, Resident #3 (R3), R5, R6, R7 and R8 reported to LPA Brown that they do not have information regarding staff not assisting R1 with medication administration and R2, R3, R4, R5, R6 and R7 all confirmed that staffs at the facility are giving their medication on time and there's no incident that staffs failed to give them their medication. S3 informed LPA Brown that S3 never met R1 and S3 does not have information on R1's medication administration.

The third allegation indicates Staff did not assist resident with obtaining medical care. LPA Brown interviewed R2, R3, R5, R7 and R8 and they all indicated that staffs’ at the facility are assisting them on obtaining medical care. S1 and S3 reported to LPA Brown that they are always assisting their residents on obtaining medical care and no incident happened at the facility that they did not assist their residents on obtaining medical care. S1 and S3 added that R1 was never their resident at the facility. Interview with S1 revealed that R1 resides at the back building of the facility operated and managed by a different owner therefore they do not have available information regarding staff not assisting R1 with obtaining medical care..

The fourth allegation indicates Staff did not provide resident with a copy of an admissions agreement. LPA Brown did not find evidence to corroborate the allegation. Interviews with R2, R3, R5, R7 and R8 indicated that staffs’ at the facility provided them with a copy of their admissions agreement. S1 and S3 reported to LPA Brown that the facility's providing a copy of admission agreement to their residents and they both indicated that there's no incident happened at the facility that their residents were not provided a copy of their admission agreement. To add to that, S1 reported to LPA Brown that R1 was a never a resident at their facility that's why there's no Admission Agreement document for R1. S1 indicated that R1 was a resident at the back building of the facility operated and managed by a different owner.

Based on the evidence, the allegations Adult residing in the facility is using illegal drugs inside of the facility (Allegation #1), Staff did not assist resident with administering medications as prescribed (Allegation #2), Staff did not assist resident with obtaining medical care (Allegation #3), Staff did not provide resident with a copy of an admissions agreement (Allegation #4) are UNSUBSTANTIATED. ***Continuation in LIC9099C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20230308123000

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: 10/27/2023

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	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: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC9099 (FAS) - (06/04)

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