198204489-12-15-2021-11-AS-JHAD-C9RSMM-20211216130011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204489
Report Date: 10/21/2021
Date Signed: 12/15/2021 03:02:22 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
10/13/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211013091228

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: 5	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Melanie Tallada-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff handles resident in rough manner.
Staff is verbally abusive to resident.

INVESTIGATION FINDINGS:

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On 10/21/21, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in in order to render investigation findings for the above allegations. LPA met with the Caregiver Primitivo Ison and explained the purpose of today’s visit.

The investigation consisted of following: Interviews and records review. On 10/21/21 conducted a Health and Safety check. LPA toured the facility with Caregiver Ison and was later met by Melanie Tallada. LPA conducted interviews with Assistant Administrator Tallada and staff members #1-3. LPA attempted to interview residents #1 and #2 but was unsuccessful. LPA interviewed residents #3-5. LPA obtained staff & residents roster, residents #1-3 admissions agreements, physicians reports, appraisal/needs and service, emergency contacts, staff #1-3 training records.

LIC 9099-C is on the next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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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Control Number 11-AS-20211013091228

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: 10/21/2021

NARRATIVE

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Investigation revealed the following:

Allegation: Staff handles resident in rough manner.

LIC 9099 is on the next page.

On 10/21/21, LPA interview Assistant Administrator Melaine Tallada regarding the above allegation she stated has not witness staff use any type of physical force on resident. She stated no resident has informed her of any type of physical abuse. LPA interviewed staff members #1-3, they stated have not used any type of force on residents and have no witness any staff hit residents. LPA attempted to interview residents #1 and #2 but was unsuccessful. LPA interviewed residents #3-#5 and one out of 5 residents stated staff #3 had pushed them.

Allegation: Staff is verbally abusive to resident.

On 10/21/21, LPA interview Assistant Administrator Melaine Tallada regarding the above allegation she stated has not witness staff yell or curse at any residents. She stated 1 resident was hard of hearing and staff would have to tall loud. Administrator all stated no residents had any concerns. LPA interviewed staff members #1-3, they stated have not yelled or curse while taking care of residents. Staff stated has not seen any one verbally abuse residents. LPA attempted to interview residents #1 and #2 but was unsuccessful. LPA interviewed residents #3-#5 and one out of 5 residents stated staff #3 would yell and curse at them.

Based on LPAs interviews conducted and records review during the investigation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and report was provided to Melanie Tallada-Administrator

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

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