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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 134602585
Report Date: 09/27/2021
Date Signed: 09/28/2021 09:20:16 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2020 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20200312091943
FACILITY NAME:SERENITY HOMEFACILITY NUMBER:
134602585
ADMINISTRATOR:CONNIE C. ESCOBARFACILITY TYPE:
735
ADDRESS:804 KEMP COURTTELEPHONE:
(760) 890-5029
CITY:CALEXICOSTATE: CAZIP CODE:
92231
CAPACITY:6CENSUS: 6DATE:
09/27/2021
UNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Licensee, Connie EscobarTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff hit client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Licensee, Connie Escobar.

During today's visit, LPA briefly toured the facility, obtained records, and interviewed staff and clients. It was alleged the Administrator hit Client #1 (C1) in the face in March 2020 and C1 sustained a small scratch less than one centimeter on their nose. C1's Physician Report reflected C1 has multiple mental disorders. C1's Behavior Functional Analysis and Individual Service Plan stated when C1 is experiencing psychiatric symptoms, C1 misinterprets others actions as being harmful. Also, C1 seeks attention or an emotional reaction from others. Local law enforcement was notified about the incident. C1 admitted they were not telling the truth and was sorry. Administrator's interview revealed they were away from the facility on personal business and did not come in contact with C1 when the incident occurred. Staff confirmed the administrator was away from the facility during the time of the incident. Facility staff revealed they did not observe a scratch on C1's nose. Facility's Progress notes reflected C1 apologizing for false statements made about the administrator hitting C1. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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 2
Control Number 08-AS-20200312091943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SERENITY HOME
FACILITY NUMBER: 134602585
VISIT DATE: 09/27/2021
NARRATIVE
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Based on interviews and record review, we are unable to confirm or deny if the administrator hit C1. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with the Licensee and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Licensee via electronic mail. An electronic read receipt confirmation was requested to
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2