198204489-6-25-2021-11-AS-JHAD-CCHVLM-20220314163206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204489
Report Date: 06/24/2021
Date Signed: 06/25/2021 11:24:45 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
05/03/2021 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: 6	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Hazel Magalona, House Manager		TIME COMPLETED:	04:20 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 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 05/06/21 & 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: 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)

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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: 06/24/2021

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 the Administrator & S#2, stated that they have never seen S#4 hit any resident. They have only heard S#4 scream at residents. They reported to administrator and licensee, but both ignored their complaints. S#3, stated that she had just gotten there, she doesn’t know anything about S#4. Interviews with R#1, R#2, R#3, & R#4, stated that they have witnessed when S#4 would yell at R1, they have never seen S#4 hit R#1 or any other resident. The administrator stated that they had suspended S#4 temporarily. 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. 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 Melanie Tallada, 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: 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)

Page: 2 of 3

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
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	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 B 06/24/2021 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555(a)a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.	1 2 3 4 5 6 7	Administrator to create a plan in which it details step by step how the facility will ensure that every meal is nutrition and it varies from week to week. The facility has until 07/07/21 to email, fax, or mail plan to LPA Soto by POC due date.
	8 9 10 11 12 13 14	This was not met as evidence by: Based on interviews and observations the meals the R#1 - R#6 stated they were served which poses a potential health and safety to persons in care.	8 9 10 11 12 13 14
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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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