198204489-3-11-2022-11-AS-JHAD-CCHVKB-20220314163004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204489
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:55:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210511114333

FACILITY NAME:	SERENITY GUEST HOME III		FACILITY NUMBER:	198204489
ADMINISTRATOR:	LOLITA ESPIRITU		FACILITY TYPE:	740
ADDRESS:	1080 VIA LA PAZ		TELEPHONE:	(310) 548-1700
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	6	CENSUS: 0	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Felicidad Ison, Care Giver		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff caused injuries to a resident while in care
Staff mishandled a resident while in care
Staff did not seek timely medical attention for a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver amended findings and decisions which supersedes any previous findings dated 062421, for the allegations listed above. Today’s complaint investigation was conducted with Filicidad Ison.

The investigation consisted of following: Interviews and Record reviews: On 05/12/21, LPA Soto interviewed Administrator Melanie, S#2 & S#3, R#1 - R#6. LPA Toured the entire facility. The LPA also requested copies of the following documents: Face sheets, Medication logs, Physician's Report, Admissions agreement, for R#1 - R#2 and entire staff file for S#4.

Based on the LPA's investigation, the investigation revealed the following. For Allegation #1- Staff caused injuries to a resident while in care .The interviews conducted with S#2, they stated that they did hear, but did not see S#4 hurt R#1, they heard S#4 screamed at R#1 about the TV remote control. R#1 & R#3, stated that S#4 hits them and screams at them all the time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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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Control Number 11-AS-20210511114333

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY GUEST HOME III	FACILITY NUMBER: 198204489
	VISIT DATE: 03/11/2022

NARRATIVE

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They reported the incidents to the administrator and licensee, but both ignored their complaints. S#3 did not see or hear anything. R#2, R#4, R#5, & R#6, stated that they heard S#4 scream at R#1 but they did not see S#4 grab R#1 arm. Later R#1 showed them R#1’s arm with the bruises. Witness #1 stated that they had seen the bruises on R#1 arm that were caused by S#4. The administrator stated that they had suspended S#4 temporarily an admitted that R#1 and R#3 reported the incident but administrator thought that R#1 was making up the incident and that R#1 had come with the bruises from R#1 previous facility. The interviews conducted concur with the above allegation.

Allegation #2 – Staff mishandled a resident while in care. Interviews conducted with S#2, stated they witness S#4 chase R#1 around the kitchen and throw a chair at R#1 but missed R#1. Interviews with R#1 and R#3, stated that S#4 always screams and yells at them all the time. They have reported the incidents to the administrator and licensee, but both ignored their complaints. S#3 did not see or hear anything. R#2, R#4, R#5, & R#6, stated that they heard S#4 scream and chase R#1 in the kitchen but did not witness incident. The administrator stated that they had suspended S#4 temporarily an admitted that R#1 and R#3 reported the incident but administrator thought that R#1 was making up the incident and that R#1 had come with the bruises from R#1 previous facility. The interviews conducted concur with the above allegation

Allegation #3 – Staff did not seek timely medical attention for a resident while in care. The interview with the Administrator, stated that they saw the bruises, but did not call 911 because, she believed that they were old bruises, that R#1 came with from another facility. That’s why they did not seek medical attention for R#1. Interviews with S#2, S#3, R#2 – R#6, they stated that knew nothing about getting medical help for R#1. The interviews conducted concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview conducted with Felicidad Ison, Care Giver. a hard copy report provided along with the Appeals rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

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