107203958-2-24-2021-24-AS-AXIG-BYKNWB-20210225094913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107203958
Report Date: 02/09/2021
Date Signed: 02/24/2021 10:03:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2020 and conducted by Evaluator David Ayers

COMPLAINT CONTROL NUMBER: 24-AS-20201029143414

FACILITY NAME:	SERENITY LIVING II		FACILITY NUMBER:	107203958
ADMINISTRATOR:	JOSIANE P JONES		FACILITY TYPE:	740
ADDRESS:	1770 W. SAN JOSE AVENUE		TELEPHONE:	(559) 436-0211
CITY:	FRESNO	STATE: CA	ZIP CODE:	93711
CAPACITY:	6	CENSUS: 3	DATE:	02/09/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Josiane Jones		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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9

Licensee is falsifying signature on medicine records

INVESTIGATION FINDINGS:

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2
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On this date, Licensing Program Analyst (LPA) David Ayers contacted the facility to discuss complaint findings via telephone due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call with Licensee Josiane Jones.

During the course of the investigation, LPA reviewed records and conducted interviews. LPA reviewed the facility’s centrally stored medication records and medication administration records(MAR’s). Medication records were complete and in compliance with regulations. Medications appeared to be administered properly according to the MAR’s. LPA interviewed facility staff and discussed the facility’s medication administration procedures. Facility Staff 1(S1) and Staff 2(S2) both stated that neither they nor the Licensee falsify any signatures on records and there are no issues with medications in the facility.

The allegation is unsubstantiated. Exit interview conducted with Licensee/Administrator Josiane Jones via telephone and a copy of this report provided via email. A read receipt confirms the licensee receives these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David Ayers	TELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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