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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 04/12/2022
Date Signed: 04/12/2022 05:55:30 PM

Unfounded


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
12/28/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20211228152000
FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR:UNAISI WAQALALAFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 6DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Unaisi Waqalala, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 04/12/2022 at 9:30 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit.

The investigation was conducted by the Department which consisted of reviews of the medical records and interviews with facility management and staff. The complaint alleges that resident sustained pressure injuries while in care. Based on the investigation, it was revealed that resident (R1) had a pressure wound when moved in.

Report continued on 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 7
Control Number 27-AS-20211228152000
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: 04/12/2022
NARRATIVE
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This Department has investigated the allegation noted above and have found that the complaint was UNFOUNDED, meaning that the allegations was false, could not have happened and/or was without a reasonable basis.

Exit interview was conducted with Administrator Unaisi Waqalala and a copy of the report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
12/28/2021 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20211228152000

FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR:UNAISI WAQALALAFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 6DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Unaisi Waqalala, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident was found covered in feces and urine on more than one occasion.
Facility staff does not meet resident's hygiene needs.
Facility lacks sufficient staff to meet the needs of the residents.
Resident accepted for care with a prohibited health condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced on 04/12/2022 at 9:30 am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit.

The investigation was conducted by the Department which consisted of reviews of the medical records, hospice records and interviews with hospice nurse. Based on the interviews and statements obtained during the investigation process, it was learned that resident (R1) was found covered in feces and urine on multiple occasions. Staff (S1) did not follow RN instructions to keep R1 clean and dry and apply barrier cream with each brief change. As a result, resident R1 hospice care plan was not followed and resident’s hygiene needs were not met.

Report continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20211228152000
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: 04/12/2022
NARRATIVE
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Additionally, a Department staff was provided entry in the facility by R2 and was later observed R2 left the facility unattended on 3/11/2022. Furthermore, it was learned that resident R1 was accepted for care with a prohibited health condition, stage 3 pressure injury. R1 has a pressure wound when moved in.

As a result of this investigation, the Department finds the allegations above to be substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

On 4/12/2022, the issuance of an Enhanced Civil Penalty was still being determined, however the Department informed the facility Administrator that a civil penalty may be assessed.

Exit interview conducted with Administrator Unaisi Waqalala. A copy of this report, LIC 9099-D, and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20211228152000
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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed... The licensee shall provide assistance in meeting necessary medical and dental needs.
This requirement is not met as evidenced by
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Licensee shall submit a plan of correction detailing how the hospice care plan will be follow by POC due date of 4/13/2022
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Based on interviews and observations, the Licensee did not ensure that hospice care plan is being followed. Staff did not follow hospice nurse instructions to keep R1 clean and dry and apply barrier cream. This poses an immediate health and safety risk to residents in care.
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Type B
04/19/2022
Section Cited
CCR
87464(f)(1)
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Basic Services. Basic services shall at a minimum include: Care and supervision.
This requirement is not met as evidenced by
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Licensee and LPA agree to: Submit a plan on how the facility will ensure that residents' hygiene needs are met by POC due date 4/19/2022.
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Based on interviews and observations, the Licensee did not ensure resident's hygiene needs are met. Resident R1 was found covered in feces and urine multiple times. This poses a potential health and safety risk to residents in care.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20211228152000
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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited
CCR
87411(a)
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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 evidence by:
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Licensee will ensure that the facility is adequately staffed at all times to meet the resident’s needs. Licensee will submit a plan to include updating LIC 500 personnel report to ensure facility is adequately staffed to be submitted by 4/13/2022. LIC 500 must be accurate and meet all labor requirements.
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Based on records and observations, the licensee did not ensure an adequate number of staff working in the care facility. Resident R2 was observed leaving the facility unattended on 3/11/2022. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.
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Type A
04/13/2022
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties. The administrator shall have the qualifications...knowledge and ability to conform to applicable laws and regulations.
This requirement is not met as evidence by:
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Administrator agrees to take training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC date, 4/13/2022.
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Based on records and observations, the licensee/administrator did not follow the requirement when admitting new resident. The facility admitted R1 with a pressure wound without knowledge or plan for care. This posed an immediate health and safety risk to resident’s in care.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20211228152000
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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
87457(c)
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Pre-Admission Appraisal - General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs
This requirement is not met as evidence by:
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The Licensee shall review residents' files to ensure each residents has a pre-admission appraisal on file and any future placement that a pre-admission appraisal is conducted. The Licensee shall provide the Department a plan on how the pre-addmission appraisal is conducted. POC due date of 4/22/2022.
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Based on interview and record review, the licensee did not ensure a pre-admission appraisal was completed for R1 prior to R1s admission. This poses a potential health and safety risk to residents in care.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7