336425532-6-13-2023-18-AS-JESL-CT2TMA-20230622145048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425532
Report Date: 11/12/2021
Date Signed: 06/13/2023 10:29:54 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201102101543

FACILITY NAME:	SERENITY HAVEN		FACILITY NUMBER:	336425532
ADMINISTRATOR:	BRANDON T. HARMISON		FACILITY TYPE:	740
ADDRESS:	24300 CANYON LAKE DR. N		TELEPHONE:	(951) 246-9465
CITY:	CANYON LAKE	STATE: CA	ZIP CODE:	92587
CAPACITY:	6	CENSUS: 4	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Brandon Harmison, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not provide resident's records to emergency personnel
Resident in care sustained an injury from an unwitnessed fall
Resident was left on the floor for an extended period of time.

INVESTIGATION FINDINGS:

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*** The following report is an amended report to the findings that were originally given on 11/12/2021***

Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to deliver findings for the allegation(s) listed above. LPA identified herself and discussed the purpose of the visit and the elements of the above allegation(s) with Administrator Brandon Harmison. The department investigated the of allegation listed above, which included observation, interviews and records review.

Allegation: Facility staff did not provide resident's records to emergency personnel.
On 11/1/20 Resident #1 (R1) had an unwitnessed fall. Per the SIR submitted it is noted that the incident/fall occurred between 2:45am-3:15am. LPA conducted interviews with caregiver Maryanne and Staff #1(S1) whom were both present at the time of the incident. Maryanne stated that the information provided was R1 medications list, insurance info and DNR. S1 also stated that R1s folder was provided to a Firefighter as they responded first.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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 18-AS-20201102101543

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SERENITY HAVEN	FACILITY NUMBER: 336425532
	VISIT DATE: 11/12/2021

NARRATIVE

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*** The following report is an amended report to the findings that were originally given on 11/12/2021.

Regarding the allegation of Resident was left on the floor for an extended period of time.
Per interviews conducted with Caregiver Maryanne, she is the staff that works the night shift, and that rounds are completed every hour. S1 happened to stop by the facility as they had forgotten a personal item that they needed to pick up. S1 stated it was not too long but could not remember exactly how long it was before medical personnel arrived. Caregiver Maryanne stated that R1 could not have been on the floor any more than 15-20 minutes that R1 was on the floor. It was confirmed that R1 did sustain a fall, and that they had to be sent out for a medical evaluation. There were not any additional witnesses identified that could corroborate the allegation. Due to insufficient evidence, LPA was unable to corroborate the allegation of Resident was left on the floor for an extended period of time, therefore the allegation is UNSUBSTANTIATED.

Regarding the allegation of Resident in care sustained an injury from an unwitnessed fall.
It was reported that R1 did sustain a fall, and that they had a cut on the bridge of their nose, and that blood had dripped along their face and hair, R1 was sent out for a medical evaluation. Per Caregiver Maryanne It is protocol for any resident to be sent out after sustaining a fall, to ensure that there are not any injuries that were not visibly observed. R1 was sent back to the facility and did not require any further medical attention. Caregiver Maryanne denied that R1 was observed to be found with blood on their face and matted in their hair. stated that she is the staff that works the night shift, and that rounds are completed every hour. Caregiver Maryanne stated that R1 could not have been on the floor any more than 15-20 minutes. Based interviews and record review, LPA was unable to corroborate the allegation of Resident in care sustained an injury from an witnessed fall, therefore the allegation is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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 at this time.

An exit interview was conducted, and a copy of this report was provided to Maryanne Harmison.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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