342700491-10-1-2021-27-AS-CACL-C7QSQB-20211012140429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 09/24/2021
Date Signed: 10/01/2021 10:45:45 AM

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
08/19/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210819120128

FACILITY NAME:	LOVE AND SERENITY II		FACILITY NUMBER:	342700491
ADMINISTRATOR:	RATU P VUNIMATANA		FACILITY TYPE:	740
ADDRESS:	5942 PARK VILLAGE ST		TELEPHONE:	(916) 476-5595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 4	DATE:	09/24/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator, Anthony Camacho		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident wandered away from the facility
Staff handled resident in a rough manner
Facility failed to report AWOL
Facility failed to report incidents to the Department

INVESTIGATION FINDINGS:

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This is an amended document to indicate the citation for substantiated allegation: Resident wandered away from the facilty is missing on the 9099-D. This deficientcy is cited on a case management visit (LIC 809-D) on 10/1/2021.

On 09/24/2021 at 3:00 PM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint findings. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that resident (R1) had AWOL'ed from the facility on 8/16/2021 and on another occasion about 3 weeks prior. R1 is conserved and has dementia. R1's LIC 602 Physician Report indicated that R1 was not allowed to leave the facility unassisted. On one occasion, neighbor found R1 wandering on the street and assisted R1 back to the facility. On 8/16/2021, neighbor found R1 on laying on the sidewalk in distress and notified facility staff to assist R1 back to the facility. During this incident, staff was observed to handled R1 in a rough manner when assisting R1 up from the ground. In addition, the administrator admitted that R1's AWOLs was not reported to Licensing. Reviewed of records reveiled that there were no incident reports submitted regarding the incidents.

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: 10/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021

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-20210819120128

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 II	FACILITY NUMBER: 342700491
	VISIT DATE: 09/24/2021

NARRATIVE

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As a result of this investigation, the Department 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. Deficiency regarding facility failed to report incidents was cited on LIC 9099-D of Complaint Control # 27-AS-20210819122759

Exit interview was conducted with Administrator Anthony Camacho, 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: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210819120128

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 II	FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/27/2021 Section Cited CCR 87468(a)(1)	1 2 3 4 5 6 7	Personal Rights. Each resident shall be accorded dignity in his/her personal relationships with staff, residents and other persons; shall be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature; and shall be accorded safe, healthful and comfortable accommodations, This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The adminsitrator shall schedule an in-service training for staff on personal rights, roles and responsibilities, that shall be completed by 9/27/2021. Also, a plan shall be developed and implemented by the facility outlining how residents personal rights will not be violated again in the future. Send proof of corrections in to CCL upon completion.
	8 9 10 11 12 13 14	Based on the investigation, the Licensee/Administrator did not ensure resident is treated with respect and accorded with dignity. On 8/16/2021, facility staff handled resident R4 in a rough manner when assisting R4 up from the ground which was observed by a bystander. This poses an imminent, Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14	The licensee shall provide proof of classes (date and time), who attended, to include signatures of staff that attended by POC due date 9/27/2021.
Type B 10/01/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator shall submit a plan to CCL on how the facility will ensure that any and all unauthorized absences (AWOLs) are reported to all required parties/entities including CCL. POC shall be submitted by POC date, 10/1/21.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, R1 AWOL'd from the facility on 08/16/21. Per R1's LIC602 physician report, R1 is unable to leave unassisted. The facility failed to submit an unusual incident report for R1's AWOL which poses a potential health and safety 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: 10/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021

LIC9099 (FAS) - (06/04)

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