198204489-3-11-2022-11-AS-JHAD-CCHVLL-20220314163206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204489
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:57:20 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
05/03/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210503152618

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:	02:15 PM
MET WITH:	Felicidad ison, Care giver		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff hit residents
Facility food quaility is not nutritional

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver amended findings and decisions for the allegations listed above that supersedes findings dated 06-24-21. Today’s complaint investigation was conducted with Felicidad Ison, Care giver.

The investigation consisted of following: Interviews and Record reviews: On 05/06/21 & 05/12/21, LPA Soto conducted interviews with the Administrator Melanie. On 05/12/21 LPA Soto interviewed S#2 - S#3, R#1 - R#6. On 05/12/21 & 06/21/21, LPA Soto attempted to interview S#4 did not answer phone call. LPA Toured the entire facility. LPA Soto also requested the following documents: Face sheets, Medication logs, Pre-Appraisals, Physician's Report, Bowel movement Log, Admissions Agreements, menu, weight log, for R#1 - R#2 and entire staff file for S#1, S#2, & S#4.

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-20210503152618

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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Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 – Staff hit residents. The interviews conducted with S#2, stated that they have never seen S#4 hit any resident. They have only heard S#4 scream at residents. S#3, stated that she had just gotten there, she doesn’t know anything about S#4. Interviews with R#3, & R#4, stated that they have witnessed when S#4 would yell at R#1, they have never seen S#4 hit R#1 or any other resident. Interview with R#2, stated that S#4 has hit R#1, R#2 has witnessed it. R#1 and R#2 stated that they had reported incidents to administrator and licensee, but both ignored their complaints The administrator stated that they had suspended S#4 temporarily and she had never heard or witness S#4 hit any resident. The interviews conducted concur with the above allegation.

Allegation #2 - Facility food quality is not nutritional. The interviews conducted with the administrator, S#2, & S#3, they all stated that the food is good and nutritional. They residents only ask for the same food: Hamburgers and hot dogs. Interviews with R#1 – R#6, stated that all they give them is hamburgers and hot dogs. Sometimes they will give them something different, but basically hamburgers and hot dogs. LPA Soto reviewed the menu; it is nutritional and offers a variety of food, but they were not following the menu and hamburgers and hot dogs cannot be the only food they serve. The food must always be nutritional. 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 was conducted with Felicidad Ison, care giver and a hard copy was provided along with Appeal 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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