198602675-11-15-2023-28-AS-RORN-CXRQ4W-20231120105101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602675
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:53:32 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/27/2022 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220927184943

FACILITY NAME:	JMO SERENITY		FACILITY NUMBER:	198602675
ADMINISTRATOR:	SANCHEZ, ELLERANNE		FACILITY TYPE:	735
ADDRESS:	20505 SHADOW MOUNTAIN RD		TELEPHONE:	(909) 957-5620
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	4	CENSUS: 4	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Alana Federspiel - House Manager		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff hit resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Alana Federspiel - House Manager and explained the purpose of the visit.

Investigation consisted of the following:

During the initial visit conducted on 09/29/22, LPA Kruz Long obtained a copy of the Staff/Client rosters, Client #1's records and Staff #2's records, interviewed Staff #1 - Staff #4 (S1-S4) and interviewed Client #2 (C2) and interviewed C3. Due to insufficient information available at the time, further investigation was needed.

(Continued on 9099-C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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 4

Control Number 28-AS-20220927184943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JMO SERENITY	FACILITY NUMBER: 198602675
	VISIT DATE: 11/15/2023

NARRATIVE

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Investigation revealed the following:
Allegation: Staff hit resident in care.
It is alleged that S2 hit C1 with a wooden spatula 3-4 times on the arm and thigh. Police were called and law enforcement responded to the call on 9/23/22 and conducted an investigation. Interview with C1 was attempted, however, C1 is non-verbal and was unable to answer interview questions. Law enforcement observed C1 for any bruising or redness in areas C1 was alleged to be hit and there were no visible marks. Upon interview with S1 (conducted by law enforcement), S1 denied hitting resident with wooden spatula but did admit to raising their voice and hitting their own hand with the wooden spatula while redirecting C1’s behavior. Per interview with C2 (conducted by law enforcement), they indicated they saw S2 hit C1 with the wooden spatula on the thigh. S1,S2 and C2 each stated that C1 was having behaviors on the date of the incident, running and slamming doors. Law enforcement obtained a video recording of incident where no there was no visual but audio of incident where law enforcement heard screaming and sounds of smacking. S2 was in the kitchen when incident occurred and did not witness incident but did hear S1 redirect C1 and raise their voice.

San Gabriel/Pomona Regional Center’s Quality Assurance Specialist conducted an investigation on 9/24/22 and was also not successful in interviewing C1 due to their intellectual disability. Specialist observed C1 in areas that they were allegedly hit and there were no signs of redness, bruising or swelling. During Specialist's interview with C2, it was stated that after hearing C1’s behaviors of running and slamming doors, C2 saw S1 standing over C1 with spatula in hand while C1 was sitting on their bed. Specialist obtained a video recording (no visual only sound heard) where the smacking noises and screaming were heard. Specialist interviewed S1 on 10/11/22 and S1 stated they did yell at C1 to stop slamming the door, which indicates that the Behavior Treatment Plan for C1 dated 7/4/22 was not followed.

LPA Kruz Long conducted an investigation on 9/29/22 and was unable to conduct interview with C1 as they were away at Day Program. LPA Long interviewed C2 and C2 stated that they saw S1 grab a wooden spatula and proceed to C1’s bedroom and then heard loud smacking sounds. C2 stated that they have witnessed S1 hit C1 with the same spatula on the arm and thigh. LPA was provided with a voice recording of incident where the smacking noises and screaming were heard. LPA interviewed S1 and S1 stated that C1 was having behaviors of running and slamming doors, S1 raised their voice at C1 while redirecting them and S1 stated they hit their own hand not the client while redirecting.
(Continued on 9099-C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20220927184943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JMO SERENITY	FACILITY NUMBER: 198602675
	VISIT DATE: 11/15/2023

NARRATIVE

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At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(A) and may be assessed at a later date.

Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview held and a copy of this report was provided along with appeal rights to Alana Federspiel.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220927184943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JMO SERENITY	FACILITY NUMBER: 198602675
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2023 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	House manager to have administrator provide copies of training that was conducted after incident occured. Copies must have date of training, names of participants, and materials that were covered during training. Training must cover clients personal rights listed under section code 80072(a)(3). These copies must be provided to LPA via email by POC due date of 11/16/23.
	8 9 10 11 12 13 14	Based on interview conducted on 9/29/22 S1 stated that they did raise their voice and smacked their own hand while redirecting C1's behavior, this constitues as an act of intimidation, which poses an Immediate, Health, Safety or Personal Rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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