<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005582
Report Date: 08/28/2023
Date Signed: 08/28/2023 01:16:17 PM

Document Has Been Signed on 08/28/2023 01:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HEALTHFACILITY NUMBER:
306005582
ADMINISTRATOR:KARIMKHANI, VALEH DRFACILITY TYPE:
772
ADDRESS:31471 PASEO DURANTELEPHONE:
(714) 656-8296
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 1DATE:
08/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Cynthia Dunkerson - Program DirectorTIME COMPLETED:
01:30 PM
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
Licensing Program Analyst (LPA) Jerome Haley made an unannounced Case Management visit to address regulation violations that were discovered during a complaint investigation. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit.

During the investigation of the complaint #22-AS-20230619163146 the following violations of Title 22 Division 6 Chapter 8 were observed.

During the complaint investigation it was discovered Staff 1 (S1) was transporting two clients when Client 1 (C1) demanded to be let out of the vehicle due to S1’s erratic driving. The client was scared for his life and called facility staff members to inform them about what was going on. C1 was very upset and shouting at the staff about what was happening. S1 was instructed to let C1 out of the van. When C1 exited the vehicle, the client had to send a pin (location) from his cell phone so staff could locate the client and pick him up.

After C1 exited the vehicle, Client 2 (C2) remained in the van with S1 and was involved in a in a minor collision/wreck. S1 was eventually instructed to park the van as staff tried to find their location. S1 could not provide the location, so the staff member on the phone told S1 to put C2 on the phone. C2 told staff they were in front Fire House Subs. Staff googled the location and found the address. When staff arrived, C2 was present but it was discovered S1 left the scene and abandoned C2.

During the investigation of the complaint mentioned above, it was also discovered that the facility failed to report this incident to the Orange County Regional office. During the complaint investigation, when interviewing facility staff members it was not clear if the incident had been reported. A search of the Regional Office SharePoint database, where are incidents reports are entered and stored did not produce any incident reports from Serene Behavioral Health. The incident was not reported.

Deficiencies will be cited under California Code of Regulations, Title 22, Division 6, Chapter 8.


A 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/28/2023 01:16 PM - It Cannot Be Edited


Created By: Jerome Haley On 08/28/2023 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
81078(a)

1
2
3
4
5
6
7
Responsibility for Providing Care & Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client’s needs.
1
2
3
4
5
6
7
Program Director Dunkerson will provide a in service training on providing care and supervision, and client safety. Program Director Dunkerson will provide a outline of the topics to be covered and a sign in sheet of staff attending the training by the POC due date.
8
9
10
11
12
13
14
This requirement is not being met as evidenced by clients being abandoned by the S1 who was transporting them. One client refused to continue to ride with S1 and had to be picked up by another staff member. Another client was eventually abandoned by S1 after the vehicle was involved in a minor collision. S1 was instructed to park and do not drive. S1 followed instructions but left the scene before the staff arrived and abandoned the client.
8
9
10
11
12
13
14
Type B
09/05/2023
Section Cited
CCR81061(a)(1)(E)

1
2
3
4
5
6
7
Reporting Requirements
(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
1
2
3
4
5
6
7
Program Director Dunkerson will read review the reporting requirements and email LPA Haley a signed statement of understanding by POC due date.
8
9
10
11
12
13
14
This requirement is not being met as evidenced by interview confirmation and a review of the Orange County Regional Office incident reports. After review there was no incident report submitted for the incident listed above.
8
9
10
11
12
13
14
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: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


LIC809 (FAS) - (06/04)
Page: 2 of 2