198602159-3-6-2023-28-AS-RORN-CPRLQV-20230309075807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602159
Report Date: 03/06/2023
Date Signed: 03/06/2023 10:22:42 AM

Unsubstantiated

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230228163511

FACILITY NAME:	HOME OF SERENITY		FACILITY NUMBER:	198602159
ADMINISTRATOR:	DELAUNAY, JESSY		FACILITY TYPE:	740
ADDRESS:	173 EAST ARROW HIGHWAY		TELEPHONE:	(909) 625-5649
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 0	DATE:	03/06/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jessy Delunay- Administrator/Licensee		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff denied Ombudsman access to the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial visit at the facility for the purpose of investigating the above-mentioned allegation. LPA met with Administrator/Licensee, Jessy Delunay, and explained the purpose for the visit.

During the visit, LPA Maldonado requested a copy of the resident and staff roster, conducted a tour of the physical plant with Jessy, and interviewed her.

The invetigation revealed the following:

Regarding allegation: Staff denied Ombudsman access to the facility.
LPA arrived at the facility and knocked at the front gate of the home- there was no answer. LPA observed a camera in the front, but no doorbell was observed.
(Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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 28-AS-20230228163511

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HOME OF SERENITY	FACILITY NUMBER: 198602159
	VISIT DATE: 03/06/2023

NARRATIVE

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LPA went around the back of the home and rang the doorbell, located outside of the gate. Administrator/Licensee Jessy opened the door and allowed LPA inside the home. The home was licensed on 11/10/16. Jessy informed LPA that since the facility has been licensed, there has never been any residents at the facility. She stated this can be confirmed by the previous Annual inspections conducted by the licensing agency. A tour of the physical plant was conducted by LPA Maldonado and Licensee. LPA inspected the 3 bedrooms and 2 bathrooms that the home consists of. All 3 bedrooms are currently occupied by the licensee's family. LPA did not observed any elderly individuals inside the home at the time of the visit, or any items throughout the house that would indicate elderly residents are currently residing at the home. Jessy informed LPA that she mailed back her original license to the licensing agency last year, in 2022, as she did not wish to continue with her business and is not sure why it is still appearing as operating. She provided LPA a written notice stating she would like to close out her license, as she has never operated, along with a copy of her driver's license and her Administrator's certificate# 6003758740, with expiration date: 08/30/2021. She states she did not renew her Administrator certificate for the same reason.

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, therefore the allegation is Unsubstantiated.

Per California Code of Regulations, Title 22 and Health and Safety Code, no deficiencies were cited during today's visit.

An exit interview was conducted with Licensee Jessy Delunay and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

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