198204489-10-12-2021-11-AS-JHAD-CCHVC3-20220314161824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204489
Report Date: 10/12/2021
Date Signed: 10/12/2021 01:25:04 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
08/25/2021 and conducted by Evaluator Ana Soto

COMPLAINT CONTROL NUMBER: 11-AS-20210825092526

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:	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	12:14 PM
MET WITH:			TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care
Resident is being pinched by staff 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 Melanie Tallada, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 09/03/21, LPA Soto conducted interviews with the House Manager and S#1, R#1 - R#3. The LPA also requested copies of the following documents: Resident and Staff Rosters, Pre-Appraisals, Physician's Report, ER visit and discharge documents, and Incident Reports.

Unsubstantiated

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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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-20210825092526

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: 10/12/2021

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following.

For Allegation 1 - Resident sustained multiple falls while in care. Interviews conducted with House Manager, S1, and R3, stated that R1 is always falling because R1 is always trying to do things for herself, R1 does not ask for help when R1 needs something. Interviews with R1, stated that R1 doesn’t ask for help because R1 feels that staff gets mad when R1 ask for help. Therefore, R1 does the things for herself and unfortunately R1 has fallen on several occasions because R1 doers not ask for help. Interviews with R2, stated that R2 has not seen R1 fall. LPA Soto reviewed records and it revealed that R1 does require help with all ADL’s and has gone to the ER for R1 falls. Interviews conducted and records reviewed does not concur with the above allegation.

Allegation 2 – resident is being pinched by staff while in care. Interviews conducted with House manager and S2, stated that they do not pinch any resident when the residents request assistance. That’s why they are there to help the resident in anything they need or ask for. Interviews with R1, stated that R1 get pinched by staff when R1 ask for any type of help. Therefore, R1 does not ask for help. Interviews with R2 & R3, stated that they have never gotten pinched or ever seen R1 get pinched by staff. Interviews conducted do not concur with the above allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated

An exit interview was conducted with Melanie Tallada, Administrator, and a hard copy was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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