<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880884
Report Date: 08/31/2023
Date Signed: 08/31/2023 01:23:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
05/06/2021 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210506160603
FACILITY NAME:AB'S HUMBLE HOME #2FACILITY NUMBER:
361880884
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:14798 CAMBRIA STTELEPHONE:
(909) 365-4265
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 4DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Ebraheem Hamed- AdministratorTIME COMPLETED:
01:33 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mishandled resident's medications while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to investigate and deliver findings for the above complaint allegation. LPA met with Administrator Ebraheem Hamed and explained the reason for the visit. During today’s visit, LPA toured the facility, interviewed residents, and interviewed staff.

For allegation, Staff mishandled resident’s medications while in care:

During facility tour, LPA observed three (3) plastic containers on the kitchen table with the resident’s medication stored in the plastic containers. Interviews conducted with the staff revealed that the medication was removed out of the original medication containers and placed in the plastic containers. The staff planned to leave the plastic medication containers on table until the resident’s ate dinner. The staff storing the resident’s medication in plastic containers on the kitchen table poses an immediate health, safety, or personal rights risk to persons in care.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 5
Control Number 18-AS-20210506160603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AB'S HUMBLE HOME #2
FACILITY NUMBER: 361880884
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
1
2
3
4
5
6
7
The licensee has agreed to read regulation 87465 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to host a training class on medication safety with the staff.
8
9
10
11
12
13
14
Based on interview and observation, the licensee did not comply with the section cited above evidenced by staff storing the resident’s medications in plastic cups on the kitchen table which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
The licensee has agreed to send LPA signed proof that each staff was present during the medication safety training. The POC is due by 9/1/2023.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
05/06/2021 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210506160603

FACILITY NAME:AB'S HUMBLE HOME #2FACILITY NUMBER:
361880884
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:14798 CAMBRIA STTELEPHONE:
(909) 365-4265
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:6CENSUS: 4DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Ebraheem Hamed- AdministratorTIME COMPLETED:
01:33 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speak inappropriately towards residents while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to investigate and deliver findings for the above complaint allegation. LPA met with Administrator Ebraheem Hamed and explained the reason for the visit. During today’s visit, LPA toured the facility, interviewed residents, and interviewed staff.

For allegation, Staff speak inappropriately towards residents while in care:

Interviews with staff revealed that the staff denied yelling and or speaking inappropriately to the residents. The staff stated that they speak to the residents with care, dignity, and respect. Interviews and document review revealed that the residents in care did not live here when the complaint was submitted to the department. Interviews with the residents revealed that they denied being yelled at or being spoken to in an inappropriate manner. The residents stated that the staff is nice and there were no concerns with being treated inappropriately by the staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210506160603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AB'S HUMBLE HOME #2
FACILITY NUMBER: 361880884
VISIT DATE: 08/31/2023
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
Overall, there was not enough evidence to collaborate the allegation listed above.

Based on evidence obtained during the investigation, the allegation listed above is deemed 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Ebraheem Hamed, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210506160603
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AB'S HUMBLE HOME #2
FACILITY NUMBER: 361880884
VISIT DATE: 08/31/2023
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
Based on the evidence gathered during today’s investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and the LIC9099D form were discussed and provided to Administrator Ebraheem Hamed, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5