198320198-12-10-2023-11-AS-JHAD-CYQRMX-20231221120926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320198
Report Date: 11/16/2023
Date Signed: 12/10/2023 03:37:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
11/06/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231106150508

FACILITY NAME:	SERENITY ONE LLC		FACILITY NUMBER:	198320198
ADMINISTRATOR:	DAVID, JIMMY S.		FACILITY TYPE:	735
ADDRESS:	1559 WOODBURY DR.		TELEPHONE:	(424) 263-5067
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	4	CENSUS: 4	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Jimmy David		TIME COMPLETED:	05:13 PM

ALLEGATION(S):

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Resident was inappropriately sexually touched by an unknown perpetrator.

INVESTIGATION FINDINGS:

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On 11/07/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. LPA was greeted by admnistrator Jimmy David. LPA explained the purpose of today's inspection visit was to conduct interviews and to deliver findings.

The investigation consisted of the following: Licensing Program Analyst (LPA) Ernand Dabuet conducted a visit on 11/07/23 and 11/16/23. LPA investigated the allegation mentioned and conducted interviews with clients and staff. Staff rosters, SIR reports, physician's reports, appraisals/needs and services plans, and IPP for client #1 (C1) and other pertinent records associated with this complaint. The Department of Social Services investigator Dennis Seng conducted a separate investigation that included an interview with client #1 (C1). A tour of the facilty on 11/07/23 and 11/16/23.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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-20231106150508

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY ONE LLC	FACILITY NUMBER: 198320198
	VISIT DATE: 11/16/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident was inappropriately sexually touched by an unknown perpetrator.
On 11/06/23, The Department received a complaint alleging client #1 (C1) was inappropriately sexually touched by an unknown perpetrator. The complainant stated (C1) did not feel safe at the Serenity One facility. The complainant reported (C1) is inappropriately touched in the genital area at night when it is dark and unable to make out who the individual is. The complainant reported the management in the facility is aware of the matter and no solution has been made. The complainant did not have further details nor the alleged date of the offense.

On 11/07/23, the Department investigated a visit to this facility. Between 3:30 pm – 4:00 pm, the Department along with Witness #1 (W1) Harbor Regional Center Provider Service Manager, and Witness #2 (W2) Harbor Regional Center Provider Relations were presented with a written letter by client #1 (C1). The details of the letter stated that (C1) fabricated the accusation and that (C1) recanted this allegation. (C1) expressed that (C1) was happy living at the facility and did not want to live anywhere else. (C1) apologized for making false statements and (C1) felt safe at the facility with other clients and staff.

On 11/07/23 at 1:36 pm – 2:30 pm, the Department interviewed (2) out of (2) staff who denied this accusation. (S1-S2) both stated that (C1) has a history of deviating from what is accurate or true. The Department reviewed (C1’s) Quarterly Report (dated: September 2023) it revealed (C1) is working with a Consultant Behaviorist for behaviors such as altering the truth, lying, fabrication of events/stories, or implying being mistreated.

On 11/08/23 at 4:39 pm, Investigator Dennis Seng interviewed client #1 (C1). (C1) stated he liked living at this facility and was happy and safe at the facility. (C1) denied ever being sexually abused, or inappropriately touched at any time while in care at the facility. (C1) claimed to have never been touched by anyone, and the report was false because (C1) was upset. (C1) claimed to get along and liked the staff and that they are helpful with (C1’s) daily living activities. (C1) expressed “Nobody touched me inappropriately here, I wrote a letter saying that I made it up because I was mad, and I apologized for making it up in the letter.” Investigator Seng showed (C1) a copy of the letter (C1) written, and (C1) confirmed it was the one (C1) had written. (C1) stated that in the letter (C1) formally recanted the allegation.
(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231106150508

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SERENITY ONE LLC	FACILITY NUMBER: 198320198
	VISIT DATE: 11/16/2023

NARRATIVE

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On 11/16/23 at 1:36 pm – 2:36 pm, the Department interviewed (3) out of (3) clients #2 -#4 (C2-C4) were complimentary of the staff. (C2-C4) described the facility to be their “home.” (C2-C4) had no concerns for their health or safety. (C2-C4) claimed there have been no inappropriate behaviors at this facility.

Harbor Regional Center (HRC) conducted its investigation and found no evidence to support this allegation.

Based on the information gathered, there is not enough evidence to corroborate the allegation.

Based on the information provider, an inspection of the facility, observation, interviews, and analysis of service records, (C1's) recant letter, the Department found no evidence to support the allegation mentioned above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiencies were identified during this visit.

An exit interview was conducted with Jimmy David, and a copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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