<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 05/08/2024
Date Signed: 05/08/2024 09:47:08 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240506102617
FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 5DATE:
05/08/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lina TuilomaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not prevent smoking marijuana on the facility grounds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Love and Serenity II RCFE on 5/8/24 at 8:30am to inform the licensee of complaint allegation mentioned above.

During this investigation LPA Gould interviewed S1 and R1 (See confidential name list LIC-811 dated 5/8/24).Based on the interviews and statements obtained during the investigation process, the allegations are substantiated because S1 admitted to LPA that a personal visitor of S1 visitor staff at the facility and the visitor smoked marijuana outside the facility.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
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 2
Control Number 27-AS-20240506102617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by statements from S1 that a personal visitor came to the facility and smoked
1
2
3
4
5
6
7
Facility will conduct training for all staff members reminding staff that they are not permitted personal visitors while at work and training that smoking marijuana while at the facility is a violation and could result in exclusion from licensed facilities. documentation of training for all staff to
8
9
10
11
12
13
14
marijuana outside the facility which poses a potential health safety or personal rights risk to residents in care.
8
9
10
11
12
13
14
 be completed and submitted by the POC due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2