306005582-8-28-2023-22-AS-AORZ-CV9KGX-20230901075416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005582
Report Date: 08/28/2023
Date Signed: 08/28/2023 01:18:30 PM

Substantiated

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
06/19/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230619163146

FACILITY NAME:	SERENE BEHAVIORAL HEALTH		FACILITY NUMBER:	306005582
ADMINISTRATOR:	KARIMKHANI, VALEH DR		FACILITY TYPE:	772
ADDRESS:	31471 PASEO DURAN		TELEPHONE:	(714) 656-8296
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	6	CENSUS: 1	DATE:	08/28/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cynthia Dunkerson - Program Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff transported clients in care while under the influence of alcohol

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the complaint allegation listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit.
The initial complaint investigation visit was conducted by LPA Jerome Haley on June 23, 2023, regarding a complaint filed on June 19, 2023. The complaint investigation consisted of interviews and document review. During the initial complaint visit LPA Haley conducted interviews with staff, clients, received documentation, and photos.

During the investigation LPA Haley interviewed 7 individuals. Two clients confirmed Staff (S4) was under the influence of alcohol. During interviews Client 1 (C1) observed White Claws in the vehicle near S4’s bag but did not know White Claw was an alcoholic beverage: “I thought they were energy drinks. I didn’t know what a White Claw was.”
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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 22-AS-20230619163146

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: SERENE BEHAVIORAL HEALTH	FACILITY NUMBER: 306005582
	VISIT DATE: 08/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

C1 requested S4 stop the vehicle and demanded to be let out due to S4’s erratic driving. After the C1 was let out the vehicle, S4 continued to drive with Client 2 (C2) still present in the van. Before the vehicle came to it’s final stop at 24100 El Toro Road Laguna Woods CA. 92637, the vehicle was involved in a minor collision. When Staff 1 (S1) arrived, the van was parked taking up two parking spaces, and lost fluids due to the wreck. It’s not clear what the van hit, due to some slight differences in the details provided; however, it’s clear and was confirmed by 7 of 7 individuals, a minor wreck did take place while S4 was driving. The van did not collide with another vehicle but had to be towed from the scene. When the van eventually came to a stop S4 admitted to being intoxicated to C2 who offered to buy S4 a sandwich to sober up. While the van was parked, S4 was observed drinking an acholic beverage that was in her possession while sitting near C2.

More than one individual interviewed claim when S1 arrived to pick up the vehicle and have it towed away, S1 took photos of two bottles of Fire Ball (alcoholic beverage) on the ground near the van and an open container of White Claw that was inside the van. S1 denied having photos of the items, but photos of the open White Claw container and pill bottle on the desk S4 had access to was provided. Photos of the van after the incident were provided as well.

Although, it’s unclear if S4 was under the influence of alcohol, pills, or a combination of alcohol and pills, it was clear S4 was impaired while transporting the clients in the van. Everyone interviewed including the clients riding with S4, confirmed the presence of alcohol in the van and/or the medication room in the facility where S4 had keys and access to before transporting the clients. Interviews and document review reveal S4 was terminated the same day of the incident June 9, 2023.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit review was conducted and copy of this report along with the appeal rights were provided at the time of this visit.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230619163146

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: SERENE BEHAVIORAL HEALTH	FACILITY NUMBER: 306005582
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/05/2023 Section Cited CCR 81072(a)(1)(2)	1 2 3 4 5 6 7	(a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.	1 2 3 4 5 6 7	The staff involved in the incident was immediately terminated. Program Director Dunkerson will have an in service training on how to spot and report staff impairment to prevent an incident like this from occurring again. Program Director Dunkerson will email LPA Haley the topics to be covered during the training and the date the training will be held by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: S4 transported clients while under the influence which resulted in one client requesting to be let out of the van and refusing to ride with the S4. Another client continued to ride with the staff member and was involved in a minor car wreck that resulted in the transportation van being towed away.	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.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3