342700491-9-2-2021-27-AS-KHOS-C6NJ5G-20210908064442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 09/02/2021
Date Signed: 09/02/2021 12:27:31 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
09/01/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210901140049

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:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Administrator, Anthony Camacho		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident was found by paramedics outside on the sidewalk.
There is no administrator oversight at the faciilty; no one is responding to phone calls or returning messages from the public.

INVESTIGATION FINDINGS:

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On 09/2/2021 at 8:50 AM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation. Upon LPAs arrival, caregiver Tawnya Dunaway 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 on 8-31-2021 resident R2 was found on the street by paramedics and brought to Kaiser Hospital for evaluation. R2 has dementia and AWOL from the facility unassisted. R2 was conserved and is not allowed to leave the facility unassisted.

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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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-20210901140049

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: 09/02/2021

NARRATIVE

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The complaint also alleges that there is no administrator oversight at the facility; no one is responding to phone calls or returning messages from the public.

Based on information gathered and LPA’s observation, the phone line was not in service during the time of the incident. LPA attempted to call the facility several times and the call went straight to voicemail. During the last two visits at the facility, the administer was not present at the facility to assist LPA.

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 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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210901140049

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: 09/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/03/2021 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 9/3/2021. 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 does not have an adequate number of staff working in the care facility. The facility has multiple incidents of residents’ AWOL from the facility. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
Type A 09/03/2021 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405(a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall devise a plan in writing and submit it to Licensing by close of business 9/3/21.
	8 9 10 11 12 13 14	Based on observation, during LPA's visit no Licensee/ administrator in facility was present in the facility to assist LPA with the visit.	8 9 10 11 12 13 14	Final plan of action shall be completed within 15 days and proof of that correction shall be submitted to Licensing in writing.

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: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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