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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881212
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:43:38 PM

Substantiated


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
10/14/2024 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20241014164913
FACILITY NAME:DELICARE HEALTH SERVICESFACILITY NUMBER:
331881212
ADMINISTRATOR:AWAD, SAMEHFACILITY TYPE:
740
ADDRESS:31416 CHEMIN CHEVALIERTELEPHONE:
(951) 506-4950
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY:6CENSUS: 6DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Saira Aguirre - CaregiverTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Licensee is not adhering to proper eviction procedures with resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Sara Martinez conducted an unannounced visit to the facility to initiate the complaint investigation regarding the allegation above. LPA conducted a tour of the facility, interviews, and requested pertinent documents related to the investigation.

Regarding the allegation "Licensee is not adhering to proper eviction procedures with resident in care" it was reported Resident One (R1) received an three (3) day eviction that did not adhere to Title 22 Regulation 87224 and Health and Safety Code 1569.683. R1's Power of Attorney (POA) received a text message from Administrator Sameh Awad on 10/14/2024 stating "Mandatory Eviction 10/16/2024 Last day tomorrow 10/15/2024". The Department has not received a written request from the Licensee for a three (3) day eviction notice for R1. Interview with Administrator Awad revealed due to R1's behaviors, a text message was sent to R1's POA informing them of a three (3) day eviction for R1. On 10/15/2024 the Department received a thirty (30) day eviction notice for R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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 3
Control Number 18-AS-20241014164913
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: DELICARE HEALTH SERVICES
FACILITY NUMBER: 331881212
VISIT DATE: 10/15/2024
NARRATIVE
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LPA conducted a record review of the thirty (30) day notice and determined the thirty (30) day notice was not in compliance with Title 22 Regulations 87224 and Health and Safety Code 1569.683 and was denied by the Department. Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report, LIC 9099 D, LIC 811 - Confidential Names, and Appeal Rights was provided to Aguirre.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20241014164913
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: DELICARE HEALTH SERVICES
FACILITY NUMBER: 331881212
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
87224(b)
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87224 Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause...This requirement was not met as evidence by:
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Licensee will continue to retain the resident and submit a ressission letter for the thirty day eviction notice prior to re-submiting. Licensee will submit a statement acknowleding they have read Title 22 Regulation 87244 and Health and Safety Code 1569.683 by the plan of correction date 10/25/2024.
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Based on interviews and records review, the licensee issued a three (3) day eviction and thirty (30) day eviction tfor R1 hat was not in compliance with Title 22 Regulations and Health and Safey Code 1569.683.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3