Sierra Pines Guest Home

Type of visit: Required - 1 Year

On 01/15/2025 at 09:30 AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with Staff-Carmencita fajardo and was granted entry to the facility. Facility manager Juana Hamed Shalaby arrived during the visit. At the time of the visit there were two (2) staff present, and twenty-three (22) residents present. The facility is a fourteen (14) bedroom, four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-five (25) non-ambulatory residents and approved for six (6) hospice waiver. The current census is twenty-three (22) residents. LPA Singh was accompanied by Staff-Carmencita Fajardo to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Singh inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands and wall lamps, storage space, and sufficient lighting; bathrooms were remodelled and clean, and appliances were operating appropriately. LPA Singh observed sufficient furniture and lighting throughout the facility. LPA Singh measured and observed the water temperatures in the bathroom to be at 112 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C ** During the tour of the facility, LPA Singh observed cleaning supplies, toxins, sharps, and other dangerous items were kept locked, inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Cabinet for the residents with the resident’s medications locked. LPA Singh observed the complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Singh reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Singh observed resident files reviewed were complete. LPA Singh reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, Dementia and other training, and health screenings. Last Fire drill completed on 11/15/2025 and Earthquake drill on 11/09/2025. Medications/Medication Administration Record (MAR) for five (5) residents and P&I were audited for three (3) residents, LPA Singh observed no issue. Liability insurance is valid from 09/2025 to 09/2026. Based on the observations made 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 (LIC809),LIC 809C were discussed and provided to Facility manager Juana Hamed Shalaby.the state’s words, verbatim · CDSS document, Jan 15, 2026

Type of visit: Required - 1 Year

On 03/12/2025 at 09:05 AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with Administrator Hanan Hamed and was granted entry to the facility. At the time of the visit there were three (3) staff present, and twenty-three (23) residents present. The facility is a fourteen (14) bedroom, four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-five (25) non-ambulatory residents and approved for six (6) hospice waiver. The current census is twenty-three (23) residents. LPA Singh was accompanied by Administrator Hanan Hamed to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Singh inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands and wall lamps, storage space, and sufficient lighting; bathrooms were remodelled and clean, and appliances were operating appropriately. LPA Singh observed sufficient furniture and lighting throughout the facility. LPA Singh measured and observed the water temperatures in the bathroom to be at 110 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C ** During the tour of the facility, LPA Singh observed cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Cabinet for the residents with the resident’s medications locked. LPA Singh observed the complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Singh reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Singh observed resident files reviewed were complete. LPA Singh reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, Dementia and other trainings, and health screenings. Last Fire drill completed on 01/8/2025. Medications/Medication Administration Record (MAR) for Resident#and P&I for R#1 and R#4 were audited, and LPA Singh observed no issue. Based on the observations made 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 (LIC809),LIC 809C were discussed and provided to Administrator Hanan Hamedthe state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Licensee is financially abusing resident.

First Complaint: Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA Singh met with Facility Licensee/Admicistrator Hanan Hamed and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation: Licensee is financially abusing resident. The investigation was conducted by LPA Beena Singh. The investigation consisted of file review and interviews with relevant parties. The allegation indicates that staff is financially abusing client in care. During the investigation, LPA Beena Singh did not find evidence to support the allegation. Interviews on11/27/2024 with Four (4) of five (5) clients indicated that there's no staff at the facility that's financially abusing them. Unsubstantiated Four (4)) of five (5) clients interviewed by LPA Singh, revealed there's no incident that happened at the facility that a staff or Staff #1 (S1) is financially abusing them, and they did not hear or witness a staff financially abusing Client #1 (C1). Moreover, interview with Licensee/ Administrator Staff#1, Client#1 has not been living in the facility since past three months and C#1 was admitted to Kaiser hospital on September 9th,2024 hospital and Innovage moved C#1 to nursing home in Los Angeles County as C#1 needed higher level of care. Per documents review, LPA Beena Singh observed in documentation that C1 was receiving Social Security benefits checks and as C#1 has no forwarding address, Staff#1 contacted Social Security Administration (SSA) to stop sending the facility until she can give SSA forwarding address and no money was used from C#1 SSA checks that has been received to the facility and SSA fund has been refunded to the SSA on 11/27/2024 and 12/06/2024. Based on the evidence found during the investigation, LPA Beena Singh found the allegations listed above to be Unsubstantiated. Unsubstantiated; meaning that 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 was discussed and provided to Facility Administrator Hanan Hamed.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 56-AS-20241126085953

Allegation investigated: Staff harassed resident in care.

First Complaint: Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPA Singh met with Facility Administrator Hanan Hamed and explained the purpose of the visit. The investigation consisted of interviews and review of records. First Allegation, Staff harassed resident in care. LPA Singh interviewed Five (5) clients and according to five (5) out of five (5) clients, no one is persuading residents to switch providers and residents has not signed any insurance papers or documents at this facility. Facility has two insurance agencies coming to the facility due to residents have insurance with them but no other insurance agency visits the facility. Unsubstantiated C#1 stated C#1 still have same insurance company. Clients at the facility deny having any issues with staff harassing residents regarding switching insurance providers. Based on the evidence found during the investigation, LPA Singh found the allegations listed above to be Unsubstantiated. Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are 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 was discussed and provided to Facility Administrator Hanan Hamed.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 56-AS-20241204113058

Allegation investigated: Staff inappropriately moved resident to another facility. Staff did not notify resident's authorized representative of the move. Staff inappropriately had resident sign doucments without authorized representative. Staff are not providing resident's authorized representative with signed documents and records.

First Complaint: Licensing Program Analyst (LPAs) Beena Singh conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Facility administrator Hanan Hamed and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation: Staff inappropriately moved resident to another facility. Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation. During interviews with facility administrator and records,she reported that R#1 was given notice of moving to another facility and R#1 family was contacted on the phone and have been informed of this move. Documents have been collected from the administrator Hana Hamed. Unsubstantiated Second Allegation: Staff did not notify resident's authorized representative of the move. Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation. During Interviews with Facility Administrator Hanan Hamed, she reported that R#1 daughter has been informed of facility moving R#1 to another facility. Records and documentation of phone communication has been provided with the report. Third Allegation: Staff inappropriately had resident sign documents without authorized representative. Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation. During interviews with staffs at the facility, all staff who were interviewed denied R#1 was being moved to other facility without the notice. According to the records R#1 is being capable of signing any documents on his own and can make decisions, all staff interviewed verified there was no evidence of a violation. Fourth Allegation: Staff are not providing resident's authorized representative with signed documents and records. Licensing Program Analyst Beena Singh conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation. During Interviews with Facility administrator and staff R#1 has not requested any documents or records from the facility as there are no Life insurance documents has been signed by R#1 while he was at the facility. Based on the evidence found during the investigation, LPA Beena Singh found the allegation listed above to be Unsubstantiated. Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are 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 was discussed and provided to Facility administrator Hanan Hamed.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 56-AS-20241001153001

Allegation investigated: Facility staff is serving as resident's power of attorney.

On 04/11/2024 at 01:45 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a complaint investigation. LPA Brown was greeted and granted entrance by a staff member and LPA Brown met with staff Carmencita Fajardo . LPA Brown identified herself and discussed the purpose of the visit and the elements of the allegation with staff Carmencita Fajardo. The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicated that Facility staff is serving as resident's power of attorney. LPA Brown was able to obtain evidence to corroborate the allegation. Interview with Resident #1 (R1) indicated that R1 does not have an idea that R1 designated Staff #1 (S1) as R1's Power of Attorney (POA). R1 reported to LPA Brown that R1 did not sign a POA document indicating S1 as R1's POA. ***Continuation on LIC9099C*** Substantiated LPA Brown interviewed S1 and S1 confirmed to LPA Brown that S1 is R1's POA. S1 revealed to LPA Brown that S1's unaware that a facility staff's not allowed as POA for a resident. LPA Brown reviewed R1's facility documents and LPA Brown observed R1's signed and notarized durable Power of Attorney assigning S1 as R1's POA on 10/18/2022. Based on LPA Brown’s observations and interviews and review of records, the preponderance of evidence standard has been met, therefore the allegation Facility staff is serving as resident's power of attorney is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Health and Safety Code) is being cited on the attached LIC9099D. An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to staff Carmencita Fajardo.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 56-AS-20240409145944

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(29)(C) · Plan of correction due date: Apr 12, 2024

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (29)To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following: (C) Serve as an agent for a resident under any general or special power of attorney. This requirement is not met as evidenced by: Based on observation, interview and record review, the Licensee did not comply with the section cited above by alowing Staff #1 (S1) as Resident #1 (R1) Power of Attorney as evidenced of Signed and Notarized Power of Attorney with date 10/18/2022 which pose an immediate health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: Licensee stated to cease S1 as the POA for R1 and start the Public Guardian Application for R1 and submit proof to LPA Brown on Plan of Correction (POC) due date. Licensee stated to submit Signed Statement of Understanding on HSC 1569.269(a)(29)(C) and a statement that will reflect that S1 will no longer be R1's POA to LPA Brown on Plan of Correction (POC) due date.

Type of visit: Required - 1 Year

On 02/23/2024 at 09:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Administrator Hanan Hamed met with LPA Melody Brown during the visit. At the time of the visit there were three (3) staff present, and twenty-three (23) residents present. The facility is a fourteen (14) bedroom, four (4) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twenty-five (25) non-ambulatory residents and approved for six (6) hospice waiver. The current census is twenty-three (23) residents. LPA Brown was accompanied by Administrator Hanan Hamed to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** During the tour of the facility, LPA Brown observed two (2) screen window in disrepair. Deficiency will be issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Cabinet for the residents with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed resident files reviewed were complete. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown found that Staff #4 (S4) does not have Health Screening Report with Tuberculosis (TB) Result. Deficiency will be issued. Also, LPA Brown observed S4 did not complete the required 24 hour initial training. Deficiency will be issued. Moreover, Administrator Hamed reported that they have one (1) dementia resident and LPA Brown observed no staff at the facility completed trainings in dementia. Deficiency will be issued. Furthermore, LPA Brown observed no earthquake drill completed at the facility. Last Fire In-Service completed on 10/24/2023 but no Fire Drill completed. Deficiency will be issued. Medications/Medication Administration Record (MAR) were audited, and LPA Brown observed no issue. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 forms, and Appeal Rights were discussed and provided to Administrator Hanan Hamedthe state’s words, verbatim · CDSS document, Feb 23, 2024

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.