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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004315
Report Date: 11/02/2020
Date Signed: 11/02/2020 04:12:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200421151202
FACILITY NAME:SERENITY LIVINGFACILITY NUMBER:
306004315
ADMINISTRATOR:PAUL DEJESUSFACILITY TYPE:
740
ADDRESS:29825 ANDREA WAYTELEPHONE:
(949) 481-2444
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
11/02/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Emilita MagdaluyoTIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Facility staff does not provide adequate supervision resulting in resident eloping from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre contacted the facility via telephone to deliver findings on a complaint investigation due to COVID-19 and pre-cautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegation with Administrator Emilita Magdaluyo. During the investigation, LPA Joseph Alejandre interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as resident medical records. Regarding the allegation; facility staff does not provide adequate supervision resulting in resident eloping from the facility; the investigation revealed the following: Resident 1 (R1) was discovered missing from the facility on the morning on April 18, 2020. The resident was located outside the facility in a neighbor’s backyard. Facility staff could not get to the resident to bring them back to the facility. Facility staff knocked on the neighbor’s front door so they could gain access to the backyard in an attempt to assist the resident. No one answered the door. The Orange County Sheriff was called. The Sheriffs retrieved the resident and escorted them back to the facility. The resident was checked by facility staff and the Sheriff and it was determined that the resident did not require medical attention. Interview with staff determined the resident left the facility through the sliding door in their room. Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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 22-AS-20200421151202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SERENITY LIVING
FACILITY NUMBER: 306004315
VISIT DATE: 11/02/2020
NARRATIVE
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The alarm on the sliding exit door had been turned off. It is undetermined who turned off the door alarm. Two staff were at the facility at the time of the elopement. The facility reported the incident to the LPA via phone on 4/21/20 (See LIC 812 dated 4/21/20). The facility has been in contact with the responsible party of R1 and their physician and has facilitated R1 being examined and tested for any medical issues to ensure R1’s continued health and safety. Administrator states facility door exit alarms will always be kept “on” and R1 will be monitored closely going forward However, these actions do not mitigate the facility’s responsibility to provide care and supervision to their residents. The preponderance of evidence gathered from interviews shows R1 did elope from the facility on 4/18/20 and the Orange County Sheriff was notified and returned the resident to the facility within an hour. 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, Chapter 8) An exit interview was conducted with Administrator Emilita Magdaluyo via telephone and a copy of this report along with attached citation and Licensee/Appeal Rights (LIC 9058 01/16) was provided to Administrator Emilita Magdaluyo via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20200421151202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SERENITY LIVING
FACILITY NUMBER: 306004315
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2020
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides:"Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not being met as evidenced by:
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Licensee to submit a detailed written plan on ensuring residents are unable to elope out of the facility. Licensee to forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure care and supervision was provided to R1. R1 eloped out of the facility on 04/18/2020 and was found in a neighbor's backyard. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3