342700491-9-2-2021-27-AS-KHOS-C6NHVE-20210908063148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700491
Report Date: 09/02/2021
Date Signed: 09/02/2021 12:28:29 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
08/23/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210823113613

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):

1
2
3
4
5
6
7
8
9

Not enough staff to meet resident's needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/2/2021 at 8:50 AM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint finding. 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.

Based on information gathered and LPA’s observation, the facility is not adequately staffed at all times to meet the resident’s needs. During LPA’s previous visit on 8/27/21, there is only one staff present at the facility. Upon LPA’s arrival resident (R3) opened the front door and greeted LPA. Staff (S1) was busy tending another resident’s needs and was not able to assist LPA. In addition, the facility had multiple incidents of residents’ AWOL from the facility.

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)

Page: 1 of 4

Control Number 27-AS-20210823113613

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

As a result of this investigation, LPA finds the allegation 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 of complaint control number 27-AS-20210901140049. Complaint date 9/1/2021.

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 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
08/23/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210823113613

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):

1
2
3
4
5
6
7
8
9

Facility is not storing medication properly
Not enough food to prepare meals

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/2/2021 at 8:50 AM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to deliver a complaint finding. 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. Based on the investigation, medications were locked and inaccessible to residents. The facility also has adequate food supply on hand.

Report continued on 9099-C

Unfounded

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)

Page: 3 of 4

Control Number 27-AS-20210823113613

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	This Department has investigated the allegations 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. This Department has therefore dismissed the complaint. Exit interview was conducted with Administrator Anthony Camacho, 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: 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: 4 of 4