342700043-9-17-2021-27-AS-KHOS-C74PXG-20210922114220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700043
Report Date: 09/17/2021
Date Signed: 09/17/2021 04:13:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210719114932

FACILITY NAME:	LOVE AND SERENITY OF ELK GROVE		FACILITY NUMBER:	342700043
ADMINISTRATOR:	HER, MIKE		FACILITY TYPE:	740
ADDRESS:	10339 SAGRES WAY		TELEPHONE:	(916) 667-8465
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	09/17/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Administrator, Mike Her		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility did not provide adequate care and supervision.
Facility does not maintain resident's room in a sanitary and safe manner.

INVESTIGATION FINDINGS:

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On 09/17/2021 at 3:30 PM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver the complaint findings. LPA met with Administrator Mike Her and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that facility is not adequately staffed at all times to meet the resident’s needs. During LPA’s previous visit on 7/20/2021 and 8/24/2021, there is only one staff present at the facility. Resident (R1) was observed to be naked and laying in bed, covered with feces all over, the bed and the bathroom. Staff (S1) stated the facility is short on staff.

Report continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 27-AS-20210719114932

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY OF ELK GROVE	FACILITY NUMBER: 342700043
	VISIT DATE: 09/17/2021

NARRATIVE

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The complaint also alleges that the facility does not maintain resident's room in a sanitary and safe manner.

Based on information gathered and LPA’s observation, resident R1’s room has trash and magazines all over the floor as well as feces. R1 stated that she accumulated a lot of junks. The facility has the responsibly to keep the residents’ room clean and sanitary.

As a result of this investigation, LPA finds the allegations above to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6 and/or Health and Safety Code.

Exit interview was conducted with Administrator Mike Her, a copy of the report, LIC 9099-D and appeal rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210719114932

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY OF ELK GROVE	FACILITY NUMBER: 342700043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure that the facility is adequately staffed at all times to meet the resident’s needs. Licensee will Submit update LIC 500 personnel report to ensure facility is adequately staffed to be submitted by 9/20/2021. LIC 500 must be accurate and meet all labor requirements.
	8 9 10 11 12 13 14	Based on records and LPA’s observation, the facility did not have an adequate number of staff working in the care facility. On LPA’s previous visits, LPA observed there is only one staff present at the facility. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
Type B 09/22/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a). Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility shall clean resident bedroom. This shall be done within 3 days. LPA will revisit facility to clear this deficiency.
	8 9 10 11 12 13 14	Based on LPA's observation. The facility did not kept resident room clean and sanitary. LPA observed R1's room has trash and magazines all over. This posed a potential, Health, Safety or Personal Rights risk to residents in care.	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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

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