342700491-4-12-2022-27-AS-KHOS-CDWMYB-20220428100117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 04/12/2022
Date Signed: 04/12/2022 05:43:46 PM

Unsubstantiated

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
03/15/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220315152819

FACILITY NAME:	LOVE AND SERENITY II		FACILITY NUMBER:	342700491
ADMINISTRATOR:	UNAISI WAQALALA		FACILITY TYPE:	740
ADDRESS:	5942 PARK VILLAGE ST		TELEPHONE:	(916) 476-5595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 6	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Unaisi Waqalala, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff attempted to rape a resident

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 allegation 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 facility records and interviews with facility management, staff and residents. During an interview with R1, R1 did not elaborate or discuss further any concerns about the rape. R1 primary concern is that someone will try to enter the bathroom while she showers despite the bathroom door having a lock on it.

Report continued on 9099-C

Unsubstantiated

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: 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 4

Control Number 27-AS-20220315152819

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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As a result of this investigation, the Department finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator Unaisi Waqalala and a copy of the report was 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: 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 4

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
03/15/2022 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20220315152819

FACILITY NAME:	LOVE AND SERENITY II		FACILITY NUMBER:	342700491
ADMINISTRATOR:	UNAISI WAQALALA		FACILITY TYPE:	740
ADDRESS:	5942 PARK VILLAGE ST		TELEPHONE:	(916) 476-5595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 6	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Unaisi Waqalala, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Residents were left unattended

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 facility records and interviews with facility management, staff and residents. Based on interviews and investigator’s observations, resident (R2) was observed leaving the facility unattended and walked down the driveway on 3/11/2022.

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: 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 4

Control Number 27-AS-20220315152819

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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As a result of this investigation, the Department finds the allegation to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies has been cited on Complaint Control # 27-AS-20211228152000, per Title 22 Regulations, Division 6.

Exit interview was conducted with Administrator Unaisi Waqalala and a copy of the report was 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: 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 4