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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200887
Report Date: 11/30/2022
Date Signed: 11/30/2022 01:20:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2022 and conducted by Evaluator Liridon Fici
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220817164926
FACILITY NAME:SERENITY HOME IIFACILITY NUMBER:
019200887
ADMINISTRATOR:SARMIENTO, EDITHFACILITY TYPE:
735
ADDRESS:40429 FOSTER STREETTELEPHONE:
(510) 731-7822
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 3DATE:
11/30/2022
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Edith, Sarmiento- AdministratorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Resident went AWOL from facility.
INVESTIGATION FINDINGS:
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On 11/30/2022 at 12:25 PM, Licensing Program Analysts (LPAs) Doni Fici and Catherine Lin arrived unannounced to conduct a subsequent complaint investigation and delivered findings on the above allegations. LPAs met and was greeted by Edith, Sarmiento, Administrator (ADM) at the facility.

Based on interviews conducted, Staff stated C1 did AWOL from the facility on 8/17/2022 around 11:00 AM. On 8/23/2022, LPAs observed a garbage can in front of the entrance door. S1 and S2 stated the garbage was place there to prevent C1 from leaving the facility. S1 stated that 1:1 care was provided from 8/13/22- 8/19/22 as part of transition to the new facility. S3 stated that C1 might need 1:1 supervision; however, C1 does not have 1:1 care & supervision at the moment. Physicians report indicates that client can not leave facility unassisted.

Continue on Lic9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
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 15-AS-20220817164926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENITY HOME II
FACILITY NUMBER: 019200887
VISIT DATE: 11/30/2022
NARRATIVE
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Based on LPAs interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099-D.

The following deficiency were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.


Exit interview conducted, and a copy of appeal rights provided along with this report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220817164926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERENITY HOME II
FACILITY NUMBER: 019200887
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision: (a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Administrator agreed to review and understand regulation regarding care and supervision, and to re-train staff and to submit proof of training to CCL by POC due date.
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Based on interviews, and records review, the licensee did not comply with the section cited above by allowing client to AWOL from the facility, which posed an immediate health, safety or personal rights risk to persons in care.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2022 and conducted by Evaluator Liridon Fici
COMPLAINT CONTROL NUMBER: 15-AS-20220817164926

FACILITY NAME:SERENITY HOME IIFACILITY NUMBER:
019200887
ADMINISTRATOR:SARMIENTO, EDITHFACILITY TYPE:
735
ADDRESS:40429 FOSTER STREETTELEPHONE:
(510) 731-7822
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 3DATE:
11/30/2022
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Edith, Sarmiento- AdministratorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Resident engaged in inappropriate activities.
INVESTIGATION FINDINGS:
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On 11/30/2022, at 12:25 PM, Licensing Program Analysts (LPAs) Liridon Fici and Catherine Lin arrived unannounced to delivery findings on the above allegation. LPAs met and was greeted by Edith, Sarmiento, Administrator (ADM) at the facility.

During the course of the investigation, LPAs interviewed RP and Administrator (ADM) regarding the above allegation. Rp stated that there was no inappropriate activity that Rp observed. LPAs witnessed patched up damages on Rp’s front door with no pictures taken. LPAs received a police report that is not relevant to the above allegation. ADM stated that she did not receive a police report during the incident that occurred on 8/17/2022, and also stated that she is not aware of any other inappropriate activities that C1 engaged in.


Continue on Lic9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220817164926
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENITY HOME II
FACILITY NUMBER: 019200887
VISIT DATE: 11/30/2022
NARRATIVE
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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, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5