198204489-6-25-2021-11-AS-JHAD-CCHVKC-20220314163004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204489
Report Date: 06/24/2021
Date Signed: 06/25/2021 11:23:54 AM

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: 6	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Hazel Magalona, House Manager		TIME COMPLETED:	05:00 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 findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Hazel Magalona, House Manager.

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.

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: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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 3

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: 06/24/2021

NARRATIVE

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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 the Administrator and S#2, they stated that they did hear, but did not see S#4, when S#4 screamed and chased R#1 around the kitchen. R#1 & R#3, stated that S#4 hits them and screams at them. They reported to 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 and that R#1, showed them R#1 arm with bruises, but they didn’t see the incident, just heard it. Witness #1 stated that they seen the bruises on R#1 arm that were caused by S#4. . The administrator stated that they had suspended S#4 temporarily. The interviews conducted concur with the above allegation.

Allegation #2 – Staff mishandled a resident while in care. The interviews conducted with the Administrator and S#2, they stated that they did hear, but did not see S#4, scream and chase R#1 around the kitchen. R#1 & R#3, stated that S#4 hits them and screams at them. They reported to 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 and that R#1, showed them R#1 arm with bruises, but they didn’t see the incident, just heard it. The administrator stated that they had suspended S#4 temporarily. 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 was conducted with Hazel Magalona, and a hard copy was provided and Appeal Rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/24/2021 Section Cited CCR 87468.2(8)	1 2 3 4 5 6 7	87468.2 To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requiremet was not met as evidence by: based on interviews and observations S#4 hit R#1, which poses a potential health and safety to persons in care	1 2 3 4 5 6 7	Administrator to create a plan in which it details step by step how the facility will ensure and take steps for this type of incident never to occur again. The facility has until 07/07/21 to email, fax, or mail plan to LPA Soto by POC due date.
Type A 06/24/2021 Section Cited CCR 87464	1 2 3 4 5 6 7	87464(2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.This requirement was not met as evidence by: Based on interviews and observationsFacility failed to call 911 for R#1.which poses a potential health and safety in persons in catr	1 2 3 4 5 6 7	Administrator to create a plan in which it details step by step how the facility will ensure and take steps for this type of incident never to occur again. The facility has until 07/07/21 to email, fax, or mail plan to LPA Soto by POC due date.
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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